Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 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 Ely Manor during CMS and state inspections, most recent first.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, compromising resident safety.
A resident with severe cognitive impairment and multiple chronic conditions did not receive showers or baths as required by their care plan and facility policy. Documentation showed only sporadic bathing over several months, with staff confirming gaps in care and a family member reporting infrequent hygiene assistance, resulting in dissatisfaction with care.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility’s obligation to follow care plans and respect resident choices.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
A resident with cognitive impairment and a history of falls sustained a serious injury when an exposed metal bracket, intended for a footboard but left uncovered at the end of the bed, impaled her buttock. Staff confirmed that nine beds had similar exposed brackets without footboards, and maintenance records showed no inspections or repairs had been performed for these hazards.
The facility did not maintain an effective QAPI program, with missed meetings and lack of required committee members, resulting in failure to identify and address deficiencies in resident care, safety, infection control, activity provision, and abuse prevention. Key data was not collected or analyzed, and no steps were taken to address known issues such as staff communication failures related to abuse.
A resident with multiple chronic conditions and mild cognitive impairment was left on the toilet and denied assistance with hygiene and clothing changes by a CNA, who responded angrily and refused to help. The incident caused the resident emotional distress and was corroborated by staff interviews and facility records.
A resident with moderate cognitive impairment and a history of falls, who was wheelchair-bound, fell from bed and was impaled by a metal bed frame, resulting in significant injuries including a deep laceration, fracture, and blood loss. The facility's investigation report to the State Agency omitted key details about the impalement and blood loss, resulting in inaccurate reporting of the incident.
A resident with a history of surgery, dysphagia, and risk for malnutrition experienced a 12% unplanned weight loss over 11 days. Despite care plan requirements and family concerns, staff did not notify the RD or physician of the significant weight loss, and there was no documentation of further evaluation or intervention.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, resulting in a deficiency related to confidentiality and record-keeping requirements.
A resident recovering from open heart surgery with a surgical wound was not provided proper Enhanced Barrier Precautions during direct care, as a CNA assisted with toileting while wearing only gloves and not a gown, despite clear signage and orders requiring full PPE. Staff interviews confirmed the expectation for PPE use, but the care plan lacked specific EBP focus and the CNA was unaware of the resident's precaution status.
The facility failed to respond to call lights promptly, affecting two residents' dignity and quality of life. One resident, with depression and diabetes, reported long wait times, especially during meals. Another resident, with a urinary tract infection and weakness, experienced distress due to delayed responses, leading to incontinence. Staff and Resident Council Minutes confirmed ongoing issues with call light response times.
The facility did not adequately address resident council concerns about lengthy call light wait times, as documented in multiple meetings. Staff interviews confirmed resident complaints, and the Nursing Home Administrator admitted that formal grievance forms were not completed for council-wide issues, leading to ongoing dissatisfaction.
A resident, who was cognitively intact and had undergone joint replacement surgery, fell while attempting to use the bathroom, resulting in a skin tear and knee pain. The LPN on duty assessed the resident and notified the DON and on-call provider but did not contact the emergency contact due to the early hour. The responsibility was passed to the next shift, but the RN did not make the call, believing all notifications were complete. The facility's policy required immediate notification of significant health status changes.
The facility failed to protect residents from abuse, with incidents involving staff-to-resident and resident-to-resident interactions. A CNA verbally abused a resident with cognitive impairments, while two residents with mental health issues engaged in physical altercations. Lack of supervision and staffing challenges contributed to these incidents.
The facility failed to implement its abuse policy when a resident with Alzheimer's and other conditions made physical contact with another resident with intellectual disabilities and mental health disorders. The incident was not reported to management until two days later, despite policy requirements for immediate reporting, leading to potential unreported abuse incidents.
A facility failed to implement a comprehensive care plan for a resident with multiple health issues, including Alzheimer's and a history of falls. Despite the care plan specifying the use of a concave mattress and fall mat to prevent falls, observations showed these interventions were not in place. Staff interviews confirmed the care plan's requirements, but the Director of Nursing noted that fall mats were being removed and the care plan should have been updated.
A facility failed to follow physician orders to obtain a urine sample for a resident with a history of UTIs, leading to a potential delay in treatment. The resident, experiencing hallucinations, had an order for a urinalysis with culture and sensitivity, which was not completed as indicated in the MAR. Interviews confirmed the oversight, and the lab results were not found in the medical record.
Two residents with significant health conditions did not consistently receive scheduled showers or bathing assistance, as required by their care plans. Documentation was lacking for missed showers, and staff interviews revealed inconsistencies in handling and recording refusals, leading to unmet personal hygiene needs.
The facility failed to provide consistent, meaningful activities for two residents with intellectual disabilities and mood disorders, leading to potential negative impacts on their well-being. Observations and interviews revealed insufficient activity staff and inadequate supervision in the memory care unit, resulting in limited engagement and behavioral issues among residents.
A resident with mobility issues fell during a transfer due to inadequate supervision and failure to follow the care plan, which required a two-person assist. The CNA involved did not consult the care plan and attempted the transfer alone, resulting in the resident experiencing pain in her left arm. Subsequent imaging showed no acute fracture but revealed severe osteoarthrosis.
Two residents in a LTC facility experienced emotional distress and frustration due to being placed in a locked memory care unit without prior notification. Both residents, who were cognitively intact, reported dissatisfaction with the noise level and restrictions on their freedom, leading to increased anxiety and a loss of independence. Staff interviews revealed that the residents were not adequately informed about their placement, contrary to the facility's policy on resident rights.
The facility failed to develop comprehensive care plans for two residents, leading to inconsistent care. A resident with Alzheimer's disease and a pressure ulcer lacked a care plan for heel protectors, resulting in inconsistent use. Another resident with severe cognitive impairment and a urinary catheter had no care plan for catheter management, leading to discomfort. These deficiencies were identified through observations and interviews, revealing inadequate care planning and communication.
A resident's care plan was not updated after the removal of a feeding tube, which had been discontinued over a month prior. Despite the resident's condition change, the care plan still included outdated information about tube feeding. Staff interviews confirmed the tube's removal, and the MDS Coordinator acknowledged the oversight in updating the care plan.
A resident with hand contractures did not receive appropriate interventions to prevent worsening of their condition. Despite recommendations for bilateral handrolls and passive range of motion exercises, these were not included in the care plan or EHR. Observations showed the resident without handrolls, and interviews revealed staff were unaware of the need for these devices, indicating a communication lapse.
A facility failed to provide a mechanically altered diet as ordered for a resident with dysphagia, resulting in the potential for aspiration and choking. The resident, who had a history of stroke, was observed eating non-pureed meals in her room without supervision, despite orders requiring pureed foods when eating alone. Staff interviews confirmed the dietary needs and the risk of airway compromise, but the nursing staff did not ensure the dietary department was informed to provide the correct meal consistency.
The facility was found deficient in maintaining cleanliness and proper storage. The dry storage room had improper drainage from the ice machine and cooler condensers, causing water issues. In the central supply room, items were stored on raw wood shelving and the floor, which were not cleanable surfaces. Environmental Services acknowledged the need for reorganization.
A resident with a femur fracture did not receive prescribed tramadol for pain management on the first two days after admission, leading to increased pain. The LPN responsible cited workload issues for not entering medication orders, and the pharmacy confirmed no urgent request was made for delivery. The medication was administered on the third day.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Provide Showers/Baths per Resident Preference and Plan of Care
Penalty
Summary
The facility failed to provide showers or baths according to the resident's preference and plan of care for one resident reviewed for Activities of Daily Living (ADL) care. The resident, who had multiple diagnoses including obstructive lung disease, heart failure, anemia, depression, anxiety, venous insufficiency, diabetes, hypertension, and arthritis, was noted to have severe cognitive impairment with a BIMS score of 2, as well as behavioral symptoms such as inattention, disorganized thinking, and rejection of care. The care plan indicated the resident required substantial to maximal assistance with bathing due to functional deficits. Documentation revealed that in March, the resident received only a few showers or baths, with some refusals, and only one documented shower or bath in April. No showers or baths were documented in May prior to discharge. Interviews with facility staff confirmed that the available documentation was complete and that there were significant gaps in the provision of showers or baths, with only one documented in April and none in May. The DON acknowledged that residents should generally be offered showers or baths twice per week according to their preferences. The facility's policy required that residents receive necessary assistance to maintain hygiene, with showers or baths scheduled according to person-centered care. The lack of consistent bathing was corroborated by a family member, who reported that the resident rarely received showers or baths, leading to dissatisfaction with care.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Inspect and Maintain Bed Safety Results in Resident Injury
Penalty
Summary
The facility failed to conduct routine inspections and maintenance of resident beds, specifically neglecting to address exposed metal brackets intended for footboards on nine beds. One cognitively impaired resident with a history of falls was found after a crash was heard, lying on her side with her left buttock impaled by a metal bracket at the end of her bed. The bracket, which was designed to hold a footboard, was exposed and had entered and pressed against the resident's buttock. Multiple staff interviews confirmed that these metal brackets, some with pointed tops extending upwards, had been present on beds in use for an extended period without footboards attached. The Maintenance Director acknowledged that the beds with exposed brackets had been in use since before his tenure began, and the Nursing Home Administrator was unaware of how long the beds had been in this condition. Review of facility work orders over several months showed that none of the nine beds with exposed brackets had been reported or addressed for maintenance. Staff interviews further confirmed the presence of the hazardous brackets and the lack of footboards, directly leading to the resident's injury.
Failure to Maintain Effective QAPI Program and Address Quality Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, resulting in the inability to identify and address multiple quality deficiencies. The QAPI committee did not consistently meet as required, with missed meetings and inadequate attendance by key members such as the Infection Preventionist, Administrator, Director of Nursing, and Medical Director. The committee also failed to collect or analyze data related to critical areas, including resident change of condition, safety and maintenance of beds, infection control practices, activity provision, and abuse prevention. Sign-in sheets confirmed irregular meetings and lack of required interdisciplinary participation. As a result of these lapses, the facility did not ensure that resident treatments were completed and documented per physician orders, timely identification and assessment of changes in resident condition, proper assembly and maintenance of facility beds, implementation of infection control practices, provision of activities to meet resident needs, and maintenance of an environment free from abuse. The Nursing Home Administrator confirmed that the facility was not tracking compliance with physician notifications or care provided as ordered, and that no steps had been taken to address identified issues such as staff communication failures related to resident-to-resident abuse.
Resident Denied Dignified Care and Assistance by Staff
Penalty
Summary
A deficiency occurred when a staff member failed to treat a resident with dignity and respect by refusing to assist with care needs. The resident, who had a history of depression, anxiety disorder, chronic obstructive pulmonary disease, and chronic systolic heart failure, was mildly cognitively impaired and had a care plan that emphasized the need for a trusting and non-threatening environment. On the day of the incident, the resident requested assistance from a CNA to obtain water basins for personal hygiene and to change clothes due to the warm temperature in the room. The CNA responded angrily, refused to help, and made dismissive remarks about the resident's ability to care for herself, leaving the resident on the toilet in distress. The incident was witnessed by an LPN, who found the resident crying, frustrated, and sad after the CNA left the room. The resident reported feeling unsafe and expressed concerns about not receiving necessary care. Documentation and interviews confirmed that the CNA spoke rudely, refused to assist with hygiene and clothing changes, and handled equipment in a manner that further upset the resident. The CNA denied the allegations during the investigation and was uncooperative in interviews. The facility's records and staff interviews corroborated the resident's account of being treated without dignity and respect, resulting in emotional distress.
Failure to Accurately Report Resident Impalement and Associated Injuries
Penalty
Summary
The facility failed to accurately report an incident of neglect involving an unsafe environment to the State Agency. A resident with moderate cognitive impairment, a history of falls, and limited mobility due to being wheelchair-bound, attempted to get out of bed and fell onto a metal bed frame. This resulted in a penetrating trauma, with the metal frame impaling the resident's left buttock by approximately 3-4 inches, causing significant blood loss, a comminuted fracture of the left inferior pubic ramus and ischial tuberosity, and a 4 cm laceration near the anal region. Emergency services documented the severity of the injuries, including the impalement and associated trauma. However, the facility's investigation report, authored by the Nursing Home Administrator, did not include critical details about the impalement, blood loss, or the extent of the injuries, instead only noting a fall and subsequent fracture discovered after hospital evaluation. During interviews, the administrator acknowledged that the information provided to the State Agency should have included all apparent injuries linked to the incident but was unable to explain the omission of the impalement and blood loss from the report. This resulted in inaccurate information being reported to the State Agency regarding the incident.
Failure to Notify RD and Physician of Significant Weight Loss
Penalty
Summary
The facility failed to assess and monitor the nutritional status of a resident who was at risk for malnutrition, resulting in a significant unplanned weight loss of 12% over 11 days. The resident had a history of surgical aftercare, dysphagia, and was on a mechanically altered diet, with documented difficulties in chewing and a preference for pureed foods. Despite being identified as at risk for malnutrition and having a care plan that required monitoring and notification of significant weight changes, there was no evidence that the Registered Dietitian (RD) or physician were notified of the resident's rapid weight loss. Family concerns about the resident's intake and weight loss were raised but not addressed by staff. Interviews with facility staff confirmed that the RD and physician should have been notified of the weight loss, as per facility policy, but this did not occur. The RD stated she relied on nursing management and the Certified Dietary Manager to monitor weights, but a change in staff may have led to the oversight. The Director of Nursing confirmed the lack of documentation regarding notification of the RD or physician. Review of physician notes also showed no acknowledgment or evaluation of the resident's significant weight loss during the relevant period.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency was identified when a resident with a recent history of open heart surgery and a midline sternum surgical wound was not provided with proper infection control measures during personal care. The resident required Enhanced Barrier Precautions (EBP) as indicated by physician orders and signage on the resident's door, specifying the use of personal protective equipment (PPE), including gowns and gloves, during high-contact care activities such as toileting and changing bed linens. Despite these requirements, a Certified Nursing Assistant (CNA) was observed providing direct personal care to the resident while only wearing gloves and not a gown, contrary to the EBP protocol. The CNA stated a lack of awareness regarding the resident's EBP status at the time of care and admitted to not wearing a gown during the incident. Interviews with facility staff, including the wound nurse, confirmed that the facility follows CDC guidelines for EBP and that staff are trained to recognize signage and use appropriate PPE. However, the care plan for the resident did not specifically address EBP, and the CNA did not adhere to the required infection control practices during the observed care event.
Delayed Call Light Response Affects Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity and respond to call lights in a timely manner, affecting two residents. Resident #104, a male with depression and type 2 diabetes mellitus, reported that his call light often took a long time to be answered, particularly during meal times. His Minimum Data Set (MDS) assessment indicated he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Resident #105, also cognitively intact with a BIMS score of 15, reported that delayed responses to his call light sometimes resulted in him urinating in his pants, causing him distress. His diagnoses included a urinary tract infection, unsteadiness on feet, and weakness. Interviews with staff, including a Certified Nurse Aide (CNA) and an Activities Assistant (AA), confirmed that residents had complained about long wait times for call light responses. The Resident Council Minutes from several months also documented ongoing issues with call light response times, including instances where aides turned off call lights without addressing resident needs and took excessive time to return. These findings indicate a pattern of inadequate response to resident needs, impacting their dignity and quality of life.
Plan Of Correction
Resident #104 and #105 continue to reside in the facility. Care plans have been reviewed and deemed appropriate. Residents residing in the facility have the potential to be affected by the deficient practice. The Director of Nursing/designee has re-educated staff on the Resident Rights Policy and the Call Light Policy. Staff members who have not received education by March 24, 2025, will be removed from the schedule until education has been received. The Director of Nursing/designee will complete an audit of 10 random call lights during and around mealtimes to ensure residents' needs are met in a timely manner. An audit will be completed once a week for four weeks, then once every month for three months, to ensure call lights are being answered in a timely manner. Results of the audits will be reported to the facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Director of Nursing is responsible for attaining and maintaining compliance. Compliance Date: March 24, 2025
Failure to Address Resident Council Concerns on Call Light Wait Times
Penalty
Summary
The facility failed to address and resolve concerns raised by the resident council regarding lengthy call light wait times. Interviews with staff, including a Certified Nurse Aide (CNA) and an Activities Assistant (AA), confirmed that residents had complained about the delays in response to call lights. The Resident Council Minutes from multiple meetings over several months documented ongoing issues with call light response times, including reports of aides turning off call lights without addressing resident issues and taking an extended time to return. The Nursing Home Administrator (NHA) acknowledged that while the activity director shared the resident council meeting minutes with the management team, a formal concern or grievance form was not completed for issues raised by the resident council as a whole. Instead, only resident-specific concerns were documented. This lack of formal documentation and tracking of resident council concerns contributed to the ongoing dissatisfaction with call light response times and the potential for resident frustration.
Plan Of Correction
No residents were identified in this citation. Residents residing in the facility have the potential to be affected by the deficient practice. The Administrator re-educated the Activities Director of the Guest/Resident Council policy and the proper use of grievance/concern forms to be used for concern resolution. The Administrator will audit resident council minutes to ensure guest/resident concerns are resolved in a timely manner and concern forms are completed appropriately. The Administrator will complete the audit monthly for four months to ensure substantial compliance. Results of the audits will be reported to the facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Administrator is responsible for attaining and maintaining compliance. Compliance Date: March 24, 2025
Delayed Notification of Resident Fall
Penalty
Summary
The facility failed to inform a resident's emergency contact of a fall in a timely manner, resulting in a delay in notification. The resident, who was cognitively intact and had undergone joint replacement surgery, fell while attempting to use the bathroom. The fall resulted in a skin tear on the right elbow and pain in the right knee. The incident was documented by an LPN, who assessed the resident and notified the Director of Nursing and the on-call provider but did not contact the emergency contact due to the early morning hour. The LPN passed the responsibility of notifying the emergency contact to the next shift, but the RN on the following shift did not make the call, believing all necessary notifications had been made. The resident expressed a preference for family notification in such events, and the facility's policy required immediate notification of significant changes in health status. The Nursing Home Administrator confirmed that emergency contacts should be notified immediately, regardless of the time of day.
Plan Of Correction
Resident #101 continues to reside in the facility. The resident's care plan has been reviewed and deemed appropriate. Residents residing in the facility have the potential to be affected by the deficient practice. The Director of Nursing/designee has re-educated the licensed nurses of the Notification of change policy. Any licensed nurse who has not received education by March 24, 2025, will be removed from the schedule until education has been received. The Director of Nursing/designee will audit fall documentation to ensure that all appropriate parties have been notified in a timely manner. The Director of Nursing/designee will conduct the audit once a week for four weeks, then once every month for three months, to ensure appropriate parties are being notified timely. Results of the audits will be reported to the facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Director of Nursing is responsible for attaining and maintaining compliance. Compliance Date: March 24, 2025
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, as evidenced by multiple incidents involving both staff-to-resident and resident-to-resident interactions. One incident involved a Certified Nursing Assistant (CNA) who was reported to have verbally abused a resident with cognitive impairments and Parkinson's disease by swearing at her and forcibly pushing her in a wheelchair against her will. The resident, who had severe cognitive impairment and was prone to hallucinations, was unable to recall the incident, but witnesses confirmed the abusive behavior. The CNA admitted to swearing but claimed it was an unintentional reaction to being scratched by the resident. Another incident involved two residents, both with significant cognitive and mental health issues, engaging in physical altercations. One resident with Alzheimer's disease and impulsiveness struck another resident with intellectual disabilities and schizoaffective disorder. The incident was not immediately reported to management, and the care plan for the aggressive resident was not updated to prevent future occurrences. A subsequent altercation occurred between the same residents, with one resident striking the other in the face, highlighting ongoing supervision and intervention issues. Additionally, a resident with severe intellectual disabilities and mood disorders was involved in an altercation where she was hit by another resident. The facility's investigation revealed that the activities aide was unable to intervene in time to prevent the physical contact. Observations noted a lack of supervision in common areas, contributing to the potential for resident-to-resident incidents. The facility's staffing challenges and lack of consistent supervision in the memory care unit were identified as contributing factors to these incidents.
Failure to Report Abuse Incident in a Timely Manner
Penalty
Summary
The facility failed to ensure that staff fully implemented the abuse policy for reporting an incident of abuse involving two residents. Resident #101, who has Alzheimer's disease, chronic fatigue, diabetes, impulsiveness, chronic pain, psychosis, COPD, and a history of stroke, made physical contact with Resident #102, who has intellectual disabilities, bipolar disorder, anxiety, schizoaffective disorder, and experiences restlessness and agitation. The incident occurred on October 19, 2024, but was not reported to management or the Administrator until October 21, 2024, when the MDS Coordinator discovered a progress note detailing the altercation. The facility's policy requires that any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown source be reported immediately to the Administrator and DON. However, the incident was not reported in a timely manner, as the agency nurse who documented the progress note did not notify management. This delay in reporting resulted in the potential for incidents of abuse going undetected, unreported, or without thorough investigation, as the facility's abuse prevention policy was not fully implemented by the staff involved.
Failure to Implement Comprehensive Care Plan for Resident at Risk of Falls
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, resulting in a lack of service to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The resident, a female with Alzheimer's disease, chronic fatigue, diabetes, impulsiveness, chronic pain, psychosis, COPD, and stroke, was identified as being at risk for fall-related injuries due to confusion, gait/balance problems, a history of falls, incontinence, medication use, and mobility issues. Despite these risks, the care plan interventions, such as placing a fall mat next to the bed and using a concave mattress, were not implemented as observed during multiple instances. Observations revealed that the resident was frequently found lying close to the edge of the bed without the prescribed concave mattress or fall mat in place. Interviews with staff, including CNAs and the Unit Manager, confirmed that the care plan specified these interventions, but they were not being followed. The Director of Nursing acknowledged that the resident should have had a concave mattress and that the facility was in the process of removing fall mats, indicating that the care plan should have been updated accordingly.
Failure to Follow Physician Orders for Urine Sample Collection
Penalty
Summary
The facility failed to ensure that nursing staff followed physician orders to obtain a urine sample for a resident, leading to a potential delay in treatment. The resident, a female with a history of Alzheimer's disease, diabetes, and urinary tract infections, was found lying on the bathroom floor experiencing hallucinations. A physician's order was issued to obtain a urinalysis with culture and sensitivity to investigate the cause of the hallucinations, with a specific instruction not to mark the order as completed in the Medication Administration Record (MAR) until the test was performed. Upon review, it was discovered that the order was not marked as completed in the MAR, indicating that the urinalysis was not performed. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the order was not executed, and the lab results were not found in the resident's medical record. This oversight resulted in a failure to adhere to the care plan, which required obtaining labs and reporting abnormal results to the physician, potentially delaying the identification and treatment of the resident's condition.
Failure to Provide Consistent Bathing Assistance
Penalty
Summary
The facility failed to consistently provide showers or bathing assistance to two residents, resulting in unmet personal hygiene needs. Resident #100, who has multiple health conditions including heart failure, diabetes, and COPD, was noted to have missed several scheduled showers over a 30-day period without documentation of refusal or explanation. The care plan for Resident #100 indicated a need for substantial or maximal assistance with bathing, yet records showed instances where showers were marked as not applicable without further clarification. Similarly, Resident #101, diagnosed with Alzheimer's disease, diabetes, and other chronic conditions, also experienced lapses in receiving scheduled showers. The care plan for Resident #101 required substantial assistance and documentation of any refusals, but records showed missed showers without proper documentation of refusal or leave of absence. Interviews with CNAs and the Unit Manager revealed inconsistencies in documenting refusals and a lack of follow-up when residents declined showers, contributing to the deficiency in care.
Inadequate Resident Activities and Supervision
Penalty
Summary
The facility failed to provide consistent, meaningful, person-centered activities for two residents, resulting in potential negative impacts on their psychosocial well-being. Resident #102, who has intellectual disabilities, bipolar disorder, anxiety, and schizoaffective disorder, was not observed participating in activities or receiving one-to-one activities as outlined in her care plan. Despite interventions being in place, such as offering distractional activities and one-to-one support, the resident had limited engagement in activities over several months, with only a few days of one-to-one activities recorded. Observations revealed that the resident often requested to go for walks but was not accommodated promptly, leading to behavioral issues. Resident #104, diagnosed with anxiety, severe intellectual disabilities, and mood disorder, also did not receive adequate one-to-one activities as recommended in her care plan. The resident was observed to be agitated and vocal when left unsupervised in the day room, and her care plan interventions, such as providing a tray table to create personal space, were not consistently implemented. The resident's limited participation in activities was noted, with only a few days of one-to-one activities recorded over several months. Interviews with staff revealed that the facility had insufficient activity staff, leading to inadequate supervision and engagement of residents in the memory care unit. The Social Services Director and other staff members acknowledged the challenges in providing consistent activities due to staffing shortages and the high number of residents. The lack of consistent staff presence and engagement in the memory care unit contributed to resident-to-resident incidents and behavioral issues, highlighting the deficiency in meeting the residents' needs for meaningful activities.
Inadequate Supervision and Care Plan Implementation Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and implement care plan interventions for a resident, resulting in a fall. The resident, who had a history of unsteadiness on feet, weakness, and low back pain, required substantial assistance with mobility due to her condition. The care plan specified that the resident needed a two-person assist for transfers, but this was not followed during the incident. On the day of the incident, a CNA attempted to transfer the resident from her wheelchair to her bed without the required assistance. The CNA mistakenly believed the resident was a one-person assist and did not consult the care plan. During the transfer, the resident became weak and fell into the bed, resulting in pain in her left upper arm. An x-ray suggested a possible fracture, but a subsequent CT scan revealed no acute fracture, though it did show severe osteoarthrosis and potential chronic issues. Interviews with staff revealed that the CNA did not use a gait belt properly and was not aware of the resident's care plan requirements. The CNA was responding to a call light and did not perform a formal assessment of the resident's needs. The incident was not initially considered a fall by the LPN who assisted afterward, and no immediate pain was reported by the resident until the following day.
Failure to Provide Homelike Environment and Autonomy
Penalty
Summary
The facility failed to provide a homelike environment that promoted autonomy for two residents, resulting in emotional distress and frustration. Resident #334, who was cognitively intact and had a history of major depressive disorder and generalized anxiety disorder, was placed in a locked memory care unit without prior notification. This placement led to increased anxiety and dissatisfaction due to the noise level and restrictions on her freedom to move around the facility. Despite being promised that the unit would be converted to a regular hall, this change had not occurred, leaving Resident #334 feeling trapped and unable to participate in activities of interest. Similarly, Resident #333, who was also cognitively intact and had a history of major depressive disorder and anxiety disorder, expressed dissatisfaction with being placed in the locked memory care unit. She felt a loss of control over her life and was unable to move freely around the facility or access the courtyard without assistance. This situation led to feelings of being overly supervised and a loss of independence, contributing to her anxiety and depression. Both residents were not informed prior to their admission that they would be placed in a locked unit, which they found distressing and contrary to their preferences for independence. Interviews with staff, including CNAs, the Admissions Director, and the Nursing Home Administrator, revealed that the residents were not adequately informed about their placement in the locked memory care unit. The facility's policy on resident rights emphasizes the importance of informing residents about their rights and the rules governing their stay, which was not adhered to in this case. The lack of communication and failure to provide a suitable environment for these residents led to significant emotional distress and a feeling of confinement, highlighting a deficiency in the facility's care and communication practices.
Deficiencies in Care Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, leading to deficiencies in their care. Resident #34, diagnosed with Alzheimer's disease, was observed without heel protectors on multiple occasions despite having a pressure ulcer on her left heel. The care plan for Resident #34 did not include any focus, goals, or interventions related to her heel wound or the use of heel protectors. Interviews with staff, including a CNA, Unit Manager, and Hospice Nurse, revealed a lack of clarity and communication regarding the care plan for Resident #34, resulting in inconsistent application of necessary pressure-relieving devices. Resident #332, who was admitted with severe cognitive impairment and a history of urinary issues, also had an incomplete care plan. Although a urinary catheter was ordered for Resident #332, the care plan did not include any management strategies for the catheter, such as hygiene, positioning, or monitoring. An incident was reported where Resident #332 experienced discomfort due to lying on the catheter tubing, which was not addressed in the care plan. The lack of a comprehensive care plan for Resident #332's catheter care led to potential complications and discomfort for the resident. The deficiencies in care planning for both residents were identified through observations, interviews, and record reviews. The facility's failure to update and implement care plans in response to the residents' changing needs and conditions resulted in inadequate care and potential harm. The Director of Nursing acknowledged the expectation for care plans to be developed for new pressure ulcers and other significant changes in residents' conditions, highlighting the oversight in these cases.
Failure to Update Care Plan After Feeding Tube Removal
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident after a significant change in condition, specifically the removal of a feeding tube. The resident, who had a history of stroke with left-sided weakness and dysphagia, was initially assessed as cognitively intact and had a care plan that included tube feeding. However, the feeding tube was accidentally dislodged and subsequently discontinued over a month prior to the survey, yet the care plan was not updated to reflect this change. Interviews with staff, including an LPN and the Unit Manager, confirmed that the feeding tube had been removed and was not replaced. Despite this, the care plan still contained outdated information regarding tube feeding. The MDS Coordinator acknowledged that the care plan should have been revised to remove the tube feeding information, as care plans are meant to be updated with any changes in a resident's condition to ensure accurate and effective care.
Failure to Implement Interventions for Hand Contractures
Penalty
Summary
The facility failed to implement necessary interventions to prevent the worsening of contractures in a resident with right and left hand contractures. The resident was admitted with these conditions, but the current care plan did not include any focus or interventions for managing the contractures. Additionally, there were no active physician orders in place for the resident's hand contractures. An occupational therapy discharge summary recommended the use of bilateral handrolls and passive range of motion exercises, but these recommendations were not reflected in the resident's electronic health record (EHR). Observations over several days revealed that the resident was not wearing handrolls or any other devices to prevent a decline in range of motion. Interviews with the rehabilitation director, registered nurse, certified nursing assistants, and licensed practical nurse unit manager indicated a lack of awareness and communication regarding the resident's need for handrolls. The rehabilitation director stated that the order for handrolls was communicated to the nursing team, but it was not entered into the EHR. Consequently, the nursing staff and CNAs were unaware of the requirement for the resident to wear handrolls, leading to the deficiency in care.
Failure to Provide Mechanically Altered Diet as Ordered
Penalty
Summary
The facility failed to provide a mechanically altered diet as ordered for a resident with a history of stroke, muscle weakness, and dysphagia, which resulted in the potential for aspiration and choking. The resident was observed eating in her room without supervision, contrary to her dietary orders that required pureed foods if she chose to eat alone. On two separate occasions, the resident was served non-pureed meals, including a taco salad and chocolate cake for lunch, and scrambled eggs and toast for breakfast, without any staff present to supervise her. Interviews with facility staff, including a unit manager, speech therapist, and registered dietitian, confirmed the resident's dietary needs and the requirement for pureed foods when eating in her room. The staff acknowledged the resident's significant risk of airway compromise due to her condition. The dietary orders were documented in the resident's care plan and Kardex, but the nursing staff failed to ensure the dietary department was informed of the resident's location to provide the correct meal consistency.
Deficiencies in Cleanliness and Storage Practices
Penalty
Summary
The facility failed to maintain cleanliness and proper storage in two areas: the dry storage room and the central supply storage room. During a tour, it was observed that the floor drain in the dry storage room was improperly used for draining the ice machine and walk-in cooler condensers. This misuse resulted in black lines between the floor tiles and visible water seeping from the gaps when walked on. In the central supply storage room, some shelving was made from raw wood, which was not smooth or easily cleanable. Clean and sanitary items, including catheter care equipment, ice bags, hair brushes, bottles of saline, reusable urinals, and personal protective equipment, were stored on the floor and on the raw wood surface. Environmental Services H acknowledged the need to reorganize the central supply to accommodate these items properly.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to provide adequate pain management for a resident who was admitted with a fracture of the right femur. The resident was prescribed tramadol, a pain medication, to be taken as needed every six hours. However, the resident did not receive the medication on the first two days following admission, resulting in increased pain. The resident's family reported the issue to the Unit Manager LPN, who assured them that the medication would be administered, but the resident still did not receive it until the third day. Interviews with staff revealed that the nurse responsible for the resident on the night of admission was unable to complete all tasks due to a heavy workload, leading to the omission of entering medication orders or contacting the pharmacy. The Unit Manager LPN acknowledged being informed of the missed medications but could not explain the delay in administration. The pharmacy confirmed that no urgent request was made to deliver the medication on the day of admission, and it was only sent on the third day.
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 164 citations issued within 25 miles in the last 12 months — including the 3 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 Allegan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allegan County Medical Care Facility | 1.3 mi | — | 8 | 0 |
| Alamo Nursing Home Inc | 11.7 mi | — | 11 | 0 |
| Life Care Center Of Plainwell | 12.3 mi | — | 20 | 0 |
| The Laurels Of Sandy Creek | 16.4 mi | — | 6 | 1 |
| Medilodge Of Westwood | 17.7 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.