Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bayside Village during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised for about 30 minutes after staff failed to properly assess elopement risk, did not provide adequate supervision, and did not respond appropriately to exit door alarms. The resident exited through a malfunctioning delayed egress door, was found outside in a ditch with complaints of cold and pain, and required transfer to the ED. Staff were inattentive, did not update care plans or assessments in response to behavioral changes, and did not follow facility policies regarding supervision and alarm response.
A resident with a Foley catheter experienced blood in the urine, swelling, and decreased urine output, with repeated findings of an overfilled catheter bag that was not emptied as required. Staff failed to document care accurately and in a timely manner, and significant changes in the resident's condition were not communicated to the physician. These deficiencies led to the resident developing a ruptured bladder, UTI, and septic shock, ultimately resulting in death.
A resident with moderate cognitive impairment and a history of falls was being assisted in a transfer by a CNA who failed to use a gait belt as required by the care plan and facility policy. Instead, the CNA held the resident by her pants and buttocks, resulting in the resident slipping, falling, and sustaining a head laceration and pelvic fracture. Documentation and interviews confirmed the care plan was not followed, leading to hospitalization for the resident.
A significant medication error occurred when an RN administered medications intended for another resident, due to improper labeling and storage of medication cups. The affected resident, with multiple chronic conditions, received several unprescribed medications and required hospital monitoring for potential adverse effects. Family notification was not documented, and facility policy regarding medication handling was not followed.
The facility failed to provide adequate staffing, resulting in unmet care needs for residents. Interviews revealed that residents experienced delays in receiving medications and assistance, with one resident falling and being left on the floor due to insufficient staff. Staff confirmed frequent understaffing, particularly during night shifts and weekends, which compromised care. The facility's staffing schedule did not meet the requirements outlined in its Facility Assessment.
The facility failed to ensure that three CNAs had the required yearly competency trainings, including demonstrations in skills and techniques necessary for resident care. The CNAs, hired at different times, lacked dated competency skills after their respective hire dates. The DON and NHA acknowledged the absence of dated competency skills, and the Facility Assessment indicated annual evaluations on 23 areas, but the surveyor received an incomplete and undated list of training on 13 areas.
The facility did not conduct annual performance reviews for three CNAs, as required by their policy. CNAs hired in 2021, 2022, and 2023 had not received reviews, confirmed by the DON and HR staff. This lapse was acknowledged by the NHA and DON, indicating non-compliance with the facility's policy.
The facility failed to maintain food safety standards, with staff not washing hands between handling soiled and clean dishes, improper cleaning of cooling collars, and incorrect sanitizer testing. Ice buildup in the freezer and dust on a fan were noted, along with splash contamination risk in the dining room. Staff U did not follow hand hygiene protocols, posing a risk to residents.
The facility failed to ensure the QAPI committee met quarterly with required members, including the Medical Director and DON, leading to potential quality-of-care concerns for all 57 residents. Several meetings lacked attendance by the Medical Director, and no meetings were held in November and December 2023, violating CMS regulations.
The facility failed to provide three CNAs with the required 12 hours of annual in-service training, as confirmed by interviews and record reviews. CNA P, S, and T did not meet the training requirement based on their hire dates, with only 9.5, 5, and 10.25 hours completed, respectively. The facility's policy mandates at least 12 hours of training annually to ensure CNA competence, a requirement acknowledged as unmet by the DON and NHA.
The facility failed to provide behavioral health care training to two CNAs, as required by their policy. The training logs showed no record of such training for these staff members, and the Facility Assessment did not include a requirement for it. The NHA and DON acknowledged this absence, which could potentially affect all 57 residents.
The facility failed to update care plans after multiple falls for several residents, including those with Alzheimer's and Parkinson's disease. Despite falls occurring, care plans were not revised to include new interventions, as acknowledged by the DON. This oversight was contrary to the facility's policies on accident prevention and fall risk assessment.
The facility failed to ensure accurate physician visits and documentation for four residents, leading to potential gaps in comprehensive medical care. Physician K's notes often contained inaccuracies, such as incorrect medication dosages and diagnoses, and lacked thorough reviews of residents' conditions. The facility's policy on physician supervision and documentation was not followed, contributing to these deficiencies.
The facility failed to label opened inhalers and eye drops with the date they were opened, as required by policy. During audits of two medication carts, it was found that several medications for multiple residents were not labeled with opening dates, leading to the potential use of expired medications. Both a registered nurse and an LPN acknowledged the oversight, and the DON confirmed the policy requirement.
A resident with Alzheimer's Disease was observed in a wheelchair with a tray table and pommel cushion, which were used as restraints without proper assessments, physician orders, or care plan documentation. The facility did not provide education on restraint risks to the resident's representative, and no interventions were attempted before applying the restraints. The facility's policy on a restraint-free environment was not followed.
A resident receiving hospice services experienced a lack of proper coordination and communication between the LTC facility and the hospice provider. The facility did not have a physician order for hospice, nor a care plan or documentation of hospice visits in the resident's medical record. Interviews with the DON and an RN revealed uncertainty about the start date of hospice services and a lack of documentation on scheduled hospice visits. The facility's policy on hospice coordination was not followed, leading to this deficiency.
A resident with depression and other medical conditions expressed feelings of depression due to the recent loss of their son. The facility failed to provide supportive visits, grief counseling, or referrals to outside services, and did not include this issue in the resident's care plan. The Social Services Designee and Nursing Home Administrator acknowledged these oversights, which were contrary to the facility's policy on providing medically related social services.
A resident with pressure ulcers did not receive timely wound treatment medication due to the facility's failure to reorder Santyl. Despite physician orders, the medication was unavailable for seven days, and staff did not contact the physician for alternative orders. The facility's policies on medication cross-matching and reordering were not followed, leading to this deficiency.
The facility failed to attempt a gradual dose reduction (GDR) for a resident on Seroquel, despite recommendations, and did not ensure accurate antipsychotic medication dosage for another resident. Discrepancies in medication orders and lack of documentation were noted, with staff unable to explain the incorrect dosage administration.
The facility failed to implement a comprehensive Water Management Plan for Legionella control, as a humidifier used in the resident area was not assessed, and only one water sample was collected annually for testing. The Maintenance Supervisor was unaware of any Legionella discussions during QA or QAPI meetings, and there was no documentation of disinfectant levels or temperature control, exposing residents to potential Legionella infections.
A cognitively impaired resident eloped from the facility after a visitor allowed her to exit. Despite being identified as an elopement risk, the resident did not have a wander alarm due to a history of cutting them off. Staff were unaware of the exit until alerted by another visitor. The facility lacked adequate supervision, especially during weekends, and had no consistent policy for wander guard placement.
Failure to Prevent Resident Elopement Due to Inadequate Assessment, Supervision, and Door Security
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of progressive neurological disease, diabetes, non-Alzheimer's dementia, anxiety, and depression was not properly assessed for elopement risk, nor adequately supervised, resulting in the resident eloping from the facility undetected for approximately 30 minutes. The resident, who had documented patterns of wandering, was able to exit the building through a 300 Hall door that did not function as intended, opening before the required 15-second delay. Staff failed to notice or respond appropriately to the resident's wandering behaviors, and the resident's care plan did not address wandering or elopement risk until after the incident occurred. Surveillance footage showed the resident wandering unsupervised throughout the facility for an extended period, including multiple attempts to exit the building. Staff were observed to be inattentive, with one LPN using a personal cell phone at the nurses' station and leaving the resident unsupervised. When the exit door alarm was triggered, staff did not conduct a head count or search outside, only resetting the alarm and looking out the window. The resident was later found outside in a ditch, inadequately dressed for the weather, complaining of cold and pain, and required transfer to the emergency department for evaluation. Documentation and interviews revealed that staff did not consistently review progress notes or update elopement risk assessments in response to changes in the resident's behavior. The resident's care plan lacked interventions for wandering prior to the incident, despite multiple documented episodes of nighttime wandering and exit-seeking. Staff were also not fully aware of or did not follow facility policies regarding supervision, response to exit alarms, and use of personal cell phones, contributing to the failure to prevent the elopement.
Removal Plan
- Elopement and Wandering Residents Policy reviewed and updated.
- All staff were made aware of mandatory all staff meeting regarding elopement policy and responsibilities during an elopement.
- Maintenance director inspected and tested 300 Hall exit door, accompanied by Surveyor.
- Additional education to all staff regarding proper functioning door alarms was initiated via text and in person.
Failure to Provide Proper Catheter Care, Timely Documentation, and Physician Notification Resulting in Resident Harm
Penalty
Summary
The facility failed to provide proper care and treatment for a resident with an indwelling Foley catheter, resulting in significant harm. The resident, who had diagnoses including benign prostatic hyperplasia, urinary retention, and type 2 diabetes, was cognitively intact and admitted with a Foley catheter in place. Over several days, staff observed and documented blood in the resident's brief and at the tip of the penis, swelling in the thigh, decreased urine output, and a distended catheter bag. Despite these findings, there was a lack of timely and accurate documentation, and significant changes in the resident's condition were not communicated to the physician as required by facility policy. Multiple staff interviews revealed that the resident's catheter bag was repeatedly found to be overfilled, sometimes described as the size of a football, and not emptied during overnight shifts. Certified Nurse Aides reported these findings to nursing staff, but there was no evidence of appropriate follow-up or documentation. Additionally, there were instances where staff were instructed to document care tasks that had not been performed, and late entries were made in the medical record up to a month after the events occurred. The facility's Director of Nursing and other staff acknowledged issues with delayed documentation, lack of investigation, and failure to notify the physician of significant changes, including blood in the urine and decreased output. The resident ultimately experienced worsening symptoms, including abdominal pain, vomiting, confusion, and neurological changes, leading to emergency transfer to the hospital. Hospital records confirmed a diagnosis of ruptured bladder, urinary tract infection, and septic shock. The facility lacked effective catheter care policies at the time of the incident, and there was no documentation of required monitoring such as weights and leg measurements, despite physician orders. The cumulative failures in care, documentation, and communication directly contributed to the resident's decline and subsequent death.
Failure to Use Gait Belt During Transfer Results in Resident Fall and Major Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate assistance and use required assistive devices during a transfer, resulting in a resident sustaining a fall with major injury. The resident, who had moderate cognitive impairment, a history of repeated falls, and required partial to moderate assistance with transfers, was being assisted by a CNA from bed to wheelchair. During the transfer, the CNA did not use a gait belt as required by the resident's care plan and facility policy, instead holding the resident by her pants and buttocks. The resident slipped and fell, hitting her head on the overbed table and sustaining a laceration and a pelvic fracture. The incident was not witnessed by a nurse, but the CNA involved provided a written statement confirming the lack of gait belt use. The resident's care plan specified the use of a gait belt and limited assistance for transfers, and the facility's policy mandated gait belt use for residents unable to transfer independently. Documentation and interviews confirmed that the plan of care was not followed at the time of the fall. Following the fall, the resident was assessed, treated for a head wound, and sent to the emergency department, where a pelvic fracture was diagnosed. The facility had not conducted monitoring audits of staff compliance with gait belt use after the incident, and the CNA involved was not available for further interview during the survey. The deficiency was directly related to the failure to follow established care plans and safety policies during resident transfers.
Significant Medication Error Due to Improper Medication Administration and Labeling
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) administered medications intended for one resident to another. The error took place after the RN prepared two medication cups for two residents with similar first initials, labeling the cups with only initials. The RN placed one cup in the medication cart drawer while the resident was being assisted by CNAs, then later mistakenly administered the wrong cup to the resident. The nurse realized the error during administration but had already given the medications. The affected resident had a history of heart failure, hypertension, diabetes mellitus, and depression, and was cognitively intact. The resident received eight medications not prescribed to her, including drugs for blood pressure, diabetes, cholesterol, and an antipsychotic. Following the error, the resident was transferred to the emergency department for monitoring due to concerns about potential adverse effects, such as hypotension. The resident reported mild dizziness and dry mouth upon arrival at the hospital, where she was monitored and later discharged back to the facility. The facility's investigation revealed that the nurse did not notify the resident's family about the transfer or the medication error, and there was no documentation showing that the resident was asked about family notification. Additionally, the facility's policy prohibits saving medication cups in the medication cart, and the nurse's method of labeling contributed to the error. No audits or monitoring of medication administration were conducted following the incident, and only the involved nurse received education regarding the error.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by interviews and record reviews. Four residents, along with three residents from a confidential resident council meeting, reported issues related to insufficient staffing. One resident fell and was left on the floor for an extended period due to a lack of available staff. Another resident experienced delays of up to three hours in receiving medications and having call lights answered. Additional residents and their representatives confirmed that the facility was short-staffed, leading to unmet care needs. Interviews with facility staff, including the Director of Nursing, Nursing Home Administrator, LPNs, and CNAs, corroborated the residents' concerns. The Nursing Home Administrator acknowledged that there were 11 open nursing positions. Staff members reported frequent understaffing, particularly during the night shift and weekends, which resulted in care being compromised. The facility's staffing schedule did not align with its Facility Assessment, which indicated a need for more CNAs than were actually scheduled during certain shifts.
Deficient Competency Training for CNAs
Penalty
Summary
The facility failed to ensure that three Certified Nurse Aides (CNAs) had the required yearly competency trainings, including demonstrations in skills and techniques necessary for resident care. CNA P, hired on February 25, 2022, did not have dated competency skills since the date of hire. CNA S, hired on April 13, 2021, also lacked dated competency skills after the date of hire. Similarly, CNA T, hired on May 27, 2023, did not have dated competency skills after the date of hire. During an interview, the Director of Nursing (DON) and Nursing Home Administrator (NHA) acknowledged the absence of dated competency skills for staff, with the DON admitting that the skills training should have been dated. The Facility Assessment, last revised on August 8, 2023, indicated that employees are evaluated annually on 23 areas regarding resident care and facility duties. However, the surveyor did not receive a checklist of these 23 areas, and the facility presented an incomplete and undated list of training on 13 areas, which the DON referenced as the staff's competency training.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for three Certified Nurse Aides (CNAs), identified as P, S, and T, which is a requirement according to their policy. CNA S was hired on April 13, 2021, CNA T on May 27, 2023, and CNA P on February 25, 2022, yet none had received a performance review since their hiring. Interviews with the Director of Nursing (DON) and Human Resource staff confirmed that no performance reviews had been conducted since 2022. This oversight was acknowledged by both the Nursing Home Administrator and the DON, indicating a lapse in adherence to the facility's policy that mandates annual reviews to ensure adequate care and meet resident needs.
Food Safety and Hygiene Deficiencies in Dietary Department
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Dietary Aide E was seen handling soiled dishes and then clean dishes without washing hands in between, violating the FDA Food Code 2017, which mandates handwashing after handling soiled equipment. Additionally, blue cooling collars used by staff were improperly cleaned, as they were only wiped down with a quaternary solution instead of being immersed, potentially leading to contamination. Further observations revealed that the concentration of sanitizer in wiping cloth buckets was not properly tested, as Kitchen Manager D did not follow the correct procedure for using test strips, resulting in an inaccurate reading. The walk-in freezer had significant ice buildup due to damaged door seals, and a fan near the dish machine was dusty, both of which are against FDA guidelines for maintaining clean and well-repaired equipment and facilities. In the dining room, the placement of a hand sink led to clean plates being exposed to splash contamination. Staff U was observed not performing hand hygiene after touching their scalp, facial hair, and clothing before handling food and utensils, contrary to the facility's hand hygiene policy. These actions and inactions collectively posed a risk of foodborne illness to the 57 residents in the facility.
QAPI Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members, as mandated by CMS regulations. The review of attendance documentation revealed that the Medical Director or their designee did not attend several meetings, including those held on 4/30/2024, 7/13/2024, 8/10/2023, 1/19/2024, 2/2/2024, 3/21/2024, 4/11/2024, and 5/9/2024. Additionally, no meetings were held in November and December of 2023, and no attendance records were found for these months. The Director of Nursing (DON) was also absent from the meeting on 1/19/2024 and 5/9/2024. The Nursing Home Administrator (NHA) acknowledged the absence of required QAPI committee members during each quarter, which is a violation of the regulation. During an interview, the NHA mentioned that the Medical Director, referred to as Physician K, only received payment for dictation provided for resident care and did not want payment for serving as the Medical Director. The facility's QAPI plan policy, which should detail the required committee member attendance per CMS regulation, was not provided by the survey exit. The absence of the Medical Director and other key members from the QAPI meetings resulted in the potential for quality-of-care concerns for all 57 residents in the facility.
Deficient CNA Training Hours
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) received the required minimum of 12 hours of annual in-service training. This deficiency was identified during interviews and record reviews. Human Resource Staff O confirmed that the annual training requirement is based on each CNA's hire date. However, CNA P, hired on February 25, 2022, had only completed 9.5 hours of training. CNA S, hired on April 13, 2021, had completed only 5 hours, and CNA T, hired on May 27, 2023, had completed 10.25 hours. The facility's policy and Facility Assessment both stipulate that CNAs must receive at least 12 hours of training annually to ensure their continuing competence. The Director of Nursing and Nursing Home Administrator acknowledged the failure to meet this requirement, which potentially affects the care needs of all 57 residents in the facility.
Lack of Behavioral Health Training for Staff
Penalty
Summary
The facility failed to ensure that behavioral health care training was provided to two of three staff members reviewed for this requirement. Specifically, Certified Nurse Aide (CNA) T, hired on May 27, 2023, and CNA S, hired on April 13, 2021, had no record of receiving behavioral health care training according to the [Vendor] computer training logs reviewed on July 10, 2024. The facility's policy on the Nurse Aide Training Program, implemented on April 11, 2024, mandates that in-service training should be provided by qualified personnel and should include behavioral health care training based on the special needs of the residents. However, the Facility Assessment did not include a requirement for behavioral health training for staff. During an interview on July 11, 2024, the Nursing Home Administrator and Director of Nursing acknowledged the absence of behavioral health training. This deficiency had the potential to result in unmet behavioral health care needs for all 57 residents in the facility.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise care plans after multiple falls for four residents, which resulted in the potential for further falls and injury. Resident #17, who had diagnoses including unsteadiness on feet and schizophrenia, experienced four falls between January and March, yet their care plan was not updated after any of these incidents. The Director of Nursing (DON) acknowledged that revisions should occur after each fall but admitted to sometimes lacking interventions to add. Similarly, Resident #47, with diagnoses including Parkinson's disease and hypertension, had a fall in July, but their care plan was not revised post-fall. The DON admitted to issues with person-centered care plans. Resident #26, diagnosed with Alzheimer's Disease and severely cognitively impaired, experienced multiple falls from May to July, but their care plan was not updated with new interventions to prevent recurrence. Resident #36, also with Alzheimer's Disease, had falls in February and April, yet their care plan did not include the use of a wheelchair tray table, which was used as a fall prevention measure. The facility's policy on accidents and supervision, as well as fall risk assessment, emphasized the need for implementing and modifying interventions to prevent accidents, which was not adhered to in these cases.
Deficient Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that physician visits accurately reviewed the total program of care for four residents, resulting in a potential lack of comprehensive and supervised medical care. The physician, identified as Physician K, did not conduct thorough reviews of the residents' medical conditions and medications during their visits. For Resident R24, the physician's notes over several months indicated the continuation of medications that had been discontinued, and the physician admitted to not verifying the accuracy of the medication information provided by the facility. Resident R26's records showed a lack of physician visit documentation after April, despite being due for a visit in June. The Health Information Coordinator (HIC) acknowledged the absence of documentation and intended to follow up with the hospital physician practice. Additionally, the physician's notes for Resident R26 included incorrect medication dosages and lacked a comprehensive review of the resident's condition. For Resident R36, the physician's notes included incorrect diagnoses and medication dosages, and there was no documentation of a comprehensive review of the resident's systems and medications. Similarly, Resident R38's records showed discrepancies in diagnoses and a lack of follow-up on a documented pressure ulcer. The Nursing Home Administrator was aware of the concerns with the physician's documentation but had not addressed them effectively. The facility's policy required physicians to actively supervise residents and document comprehensive progress notes, which was not adhered to in these cases.
Failure to Label Opened Medications
Penalty
Summary
The facility failed to ensure that inhalers and eye drops were labeled with the dates when they were opened, as per the facility's policy. During an audit of the 100-hall medication cart, it was observed that five bottles of opened eye drops for four different residents were not labeled with the date they were opened. Additionally, three opened inhalers for two different residents were also not labeled with the date they were opened. One of these inhalers was found in a clear plastic bag with a pharmacy label indicating it was dispensed on 5/30/24, and a registered nurse confirmed that it was expired as inhalers are considered good for six weeks after opening. Similarly, an audit of the 300-hall medication cart revealed two opened eye drop bottles for one resident and four opened inhalers for two different residents, none of which were labeled with the date they were opened. Both the registered nurse and the licensed practical nurse involved acknowledged that the medications should have been labeled with the date when opened. The Director of Nursing confirmed that the facility's policy requires eye drops and inhalers to be labeled with the date they are opened, as their discard dates are based on this information rather than the expiration dates.
Failure to Ensure Proper Use and Documentation of Restraints
Penalty
Summary
The facility failed to ensure that appropriate assessments, physician orders, risk education, medical justification, and care plans for restraints were in place for a resident with Alzheimer's Disease. The resident was observed sitting in a wheelchair with a tray table attached, which secured her in the wheelchair, and a pommel cushion. There was no documentation in the care plan for the use of these restraints, and the Minimum Data Set (MDS) did not code the use of physical restraints. The facility did not have physician's orders for the tray table or pommel cushion, and the Director of Nursing (DON) confirmed that no restraint assessments or education on the risks of restraint usage had been provided to the resident's representative. The DON provided a sheet of paper with a note from the resident's daughter requesting the use of a tray table for safety and positioning, but there was no evidence of a formal consent process or discussion of potential risks. The DON admitted that no interventions had been attempted prior to applying the restraints and that the Occupational Therapist (OT) and Physical Therapist Assistant (PTA) had no information on the restraints. The facility's policy on a restraint-free environment was not followed, as there was no determination of a specific medical symptom requiring the use of restraints, nor was the care plan updated to address risks related to restraint use.
Failure in Hospice Care Coordination
Penalty
Summary
The facility failed to ensure proper collaboration and communication with the hospice provider for a resident receiving hospice services. The resident, initially admitted for skilled therapy, experienced a severe health decline and began receiving hospice care. However, the facility did not have a physician order for hospice in the resident's medical record, nor was there a care plan for hospice services. Additionally, hospice visit notes and documentation were missing from the resident's medical record. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed that the hospice documentation was expected to be in a binder at the nurses' station or in the resident's room, but upon review, the binder lacked the necessary hospice documentation. The DON and RN were uncertain about the exact start date of hospice services for the resident, and there was no clear coordination of care plans between the facility and hospice. The RN mentioned that hospice would call on the day of their visits, but there was no documentation on staffing sheets regarding scheduled hospice visits. Hospice documentation received later indicated that the resident started hospice services on a specific date, but the hospice certification and plan of care lacked a physician's signature or date. The facility's policy on coordination of hospice services emphasized the need for communication and a coordinated care plan, which was not adhered to in this case.
Failure to Provide Adequate Social Services for Grieving Resident
Penalty
Summary
The facility failed to provide adequate medically related social services to a resident, identified as Resident #15, who was reviewed for social services care. The resident had been admitted to the facility with diagnoses including depression, heart failure, hypertension, and diabetes mellitus. Despite having intact cognition, as indicated by a perfect score on the Brief Interview for Mental Status, the resident expressed feelings of depression related to the recent loss of their son, who had cerebral palsy. The resident reported that the staff or social worker did not engage in discussions about this loss. The Social Services Designee (SSD) acknowledged that no supportive services or emotional support were provided to the resident regarding the loss of their son. The SSD admitted to not discussing grief counseling or offering outside agency support to the resident, nor was there any inclusion of this issue in the resident's care plan. The Nursing Home Administrator confirmed these oversights, noting that the SSD did not address the loss, implement a care plan, or offer support or outside services during the most recent assessment. The facility's policy on social services, which mandates the provision of medically related social services to maintain residents' well-being, was not adhered to in this case.
Failure to Provide Timely Wound Treatment Medication
Penalty
Summary
The facility failed to ensure the timely reorder and acquisition of Santyl, a wound treatment medication, for a resident with pressure ulcers. The resident, who had a history of partial traumatic amputation of the right great toe, required Santyl for multiple wound sites as per physician orders. However, from July 3rd to July 9th, the medication was unavailable, and there was no documentation of any attempt to contact the physician for a change in orders. During interviews, the RN and LPN involved in the resident's care confirmed the unavailability of Santyl and acknowledged that no action was taken to address the issue. The RN was unaware of the reason for the medication's absence, and the LPN did not inquire about the missing medication or document any communication with the physician. The Director of Nursing confirmed the lack of Santyl and the absence of any documented attempts to resolve the issue. The facility's policies on medication cross-matching and reordering were not followed, as evidenced by the failure to reorder Santyl when it was running low. The Medication Cross Match policy required a weekly check to ensure sufficient medication supply, and the Medication Reordering policy mandated reordering when doses were low. These policies were not adhered to, resulting in the resident going without the prescribed wound treatment medication for seven days.
Failure to Attempt GDR and Ensure Accurate Medication Dosage
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for a resident prescribed psychotropic medications, specifically Seroquel, despite a recommendation for GDR in the psychological assessment. The resident, who was admitted with diagnoses including Alzheimer's disease, psychotic disorder with delusions, and depression, had no documented evidence of acceptance or declination of the GDR recommendation for Seroquel. Interviews with facility staff confirmed that no GDR was completed in the last year, and no clinical rationale for the lack of an attempted dose reduction was provided. Additionally, the facility failed to ensure accurate antipsychotic medication dosage for another resident, who was observed with abnormal involuntary facial movements suggestive of antipsychotic medication use. The resident's medication orders included an antipsychotic dosed at 3 mg twice daily, which was not signed by a physician. Discrepancies were found between the physician's documentation, psychiatric service provider's notes, and the current medication order, with no recommendations from the consultant pharmacist regarding the antipsychotic medication. Interviews with facility staff, including the social services designee and nurse manager, revealed a lack of documentation for physician visits and medication orders. The facility's administrator and director of nursing were unable to explain the discrepancy in the antipsychotic medication dosage, and no information was found to justify the administration of 3 mg twice daily instead of the documented 2 mg twice daily.
Failure to Implement Comprehensive Water Management Plan for Legionella Control
Penalty
Summary
The facility failed to develop and implement a comprehensive Water Management Plan (WMP) for controlling Legionella in its potable water supply system. During an inspection, it was observed that a humidifier in the boiler room was used to aerosolize potable water into the resident area, but this device had not been assessed for Legionella control. The Maintenance Supervisor (MS) admitted that the facility only collected one water sample per year for Legionella testing, which is insufficient according to the facility's own WMP guidelines. The WMP outlined specific control measures, including temperature management and disinfectant level control, but these were not being documented or monitored effectively. Further interviews revealed that the Maintenance Supervisor was unaware of any discussions regarding Legionella during the facility's Quality Assurance (QA) or Quality Assurance and Performance Improvement (QAPI) meetings. The facility's WMP required regular monitoring and reporting of water management activities, but there was no documentation of disinfectant levels, temperature control, or risk assessments related to the humidifier. This lack of documentation and oversight indicates a significant gap in the facility's infection prevention and control program, potentially exposing all 57 residents to the risk of Legionella-related respiratory infections.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent an elopement for a cognitively impaired resident. The incident occurred when a visitor entered the building and allowed the resident to exit. The resident, who had severe cognitive impairment and a history of wandering, was found at a nearby gas station and returned to the facility by a former employee who recognized her. Staff were unaware of the resident's exit until alerted by another visitor who had taken a photograph of the resident at the gas station. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a history of wandering behavior. Despite being identified as an elopement risk, the resident did not have a wander/elopement alarm due to a history of cutting off the alarms. The facility's Elopement Risk binder included the resident's information, but there was no consistent process or policy for determining the placement of wander guards on residents at risk of elopement. Interviews with staff and family members revealed that the facility lacked adequate supervision, especially during weekends when staffing levels were lower. The facility's policy on elopements and wandering residents emphasized the need for adequate supervision and person-centered care plans, but these measures were not effectively implemented. Surveillance video confirmed that no staff were present near the entrance doors when the resident exited the building.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near L' Anse
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Canal View - Houghton County | 26 mi | — | 12 | 0 |
| Portagepointe | 26.8 mi | — | 0 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 26.8 mi | — | 0 | 0 |
| Greentree Of Hubbell Rehabilitation And Health | 28.2 mi | — | 12 | 0 |
| Mission Point Nsg & Phy Rehab Ctr Of Ishpeming | 39.8 mi | — | 0 | 0 |
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