Marquette County Medical Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Ishpeming, Michigan.
- Location
- 200 West Saginaw Street, Ishpeming, Michigan 49849
- CMS Provider Number
- 235321
- Inspections on file
- 15
- Latest survey
- May 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Marquette County Medical Care Facility during CMS and state inspections, most recent first.
Surveyors identified that the facility did not have emergency preparedness policies and procedures in place for the loss of natural gas, as required. This deficiency was confirmed by the Maintenance Director during record review, indicating the facility failed to address how operations would be maintained if natural gas service was interrupted.
A review of facility records and confirmation by the Maintenance Director revealed that the required monthly inspection of the hood suppression system was not conducted for one month, resulting in noncompliance with NFPA 96 standards for cooking facility fire protection.
The facility did not ensure that fire alarm signals were transmitted to the fire alarm company within a reasonable timeframe during third shift fire drills, as confirmed by the Maintenance Director during record review.
The facility did not perform specific gravity or conductance testing of generator batteries for several months, as required by NFPA standards. This lapse in maintenance protocol was confirmed by the Maintenance Director and could impact the reliability of emergency power during outages.
Surveyors found that a posted exit door from the solarium to the 600 wing was equipped with 15-second delayed egress hardware but lacked the required signage indicating, "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS," as specified by NFPA 101. The Maintenance Director confirmed the absence of this signage during the survey.
A door leading to the exterior in the 700 wing was not properly labeled with a 'NO EXIT' sign, as required, which could cause confusion during an emergency. The deficiency was confirmed by the Maintenance Director, and exit signage was not in compliance with required standards for display and illumination.
Battery-operated smoke detectors in resident rooms on two wings were found to have exceeded their 10-year lifespan and were still in use, as confirmed by the Maintenance Director during inspection and record review.
A hot water pipe was observed being supported and hanging from a sprinkler pipe in the 300 wing mechanical room, contrary to NFPA 13 requirements for sprinkler system installation. This was confirmed by the Maintenance Director during the survey.
Surveyors found that vestibule doors to the courtyard from the 500 and 600 wings did not close to a positive latch, as required for smoke resistance. This deficiency was confirmed by the Maintenance Director during the inspection.
Surveyors observed that the main entrance cross corridor smoke barrier doors did not fully close as required by LSC standards. This deficiency, confirmed by the Maintenance Director, could affect 20 occupants in the event of a fire.
Multiple hospital-grade electrical outlets in resident rooms failed inspection, and there was no documentation showing that these outlets were repaired or replaced as required. This deficiency was confirmed by the Maintenance Director.
The facility failed to develop a care plan and offer diagnostic testing or specialist consultation for a resident experiencing prolonged nausea and vomiting, resulting in significant weight loss, decline in ADLs, and multiple pressure injuries. Despite numerous progress notes documenting the resident's condition, no actions were taken to address the root cause until the day of the surveyor's interview.
The facility failed to prevent and manage pressure ulcers for two residents, leading to the development and worsening of multiple stage II pressure ulcers. Inadequate implementation of care plan interventions, unsuitable equipment, and delayed physician follow-up contributed to the deficiency.
The facility failed to update and revise care plans to prevent falls for three residents, resulting in falls with major injuries. Despite high fall risk scores and multiple incidents, appropriate interventions were not documented or implemented. The DON and RN/Rehab Coordinator acknowledged the deficiencies in care plan updates.
A resident was left unattended on the toilet with both the bathroom and room doors open, compromising their privacy and dignity. Another resident entered the room, and staff acknowledged the failure to ensure privacy and prevent wandering.
Deficient Emergency Preparedness Policy for Natural Gas Interruption
Penalty
Summary
The facility failed to develop and implement emergency preparedness policies and procedures specifically addressing the loss of natural gas to the building. During a record review, it was found that there were no established policies outlining how the facility would maintain operations in the event of an interruption to the natural gas supply. This omission was identified as a deficiency in the facility's emergency preparedness planning. The deficiency was confirmed during an interview with the Maintenance Director at the time of the record review. The lack of a policy for natural gas interruption means the facility did not meet the requirement to review and update emergency preparedness policies and procedures at least annually, as mandated. This finding could potentially affect all occupants in the event of an emergency involving the loss of natural gas.
Plan Of Correction
Element 1: Policy for Natural Gas Outage created on 06/04/2025. Element 2: All residents have the potential to be impacted by this deficiency. Best practice is to have a policy surrounding natural gas outage. Element 3: Physical plant manager and Administrator created policy and staff were educated on 06/05/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance.
Failure to Complete Required Monthly Hood Suppression Inspection
Penalty
Summary
The facility failed to ensure that cooking facilities were protected in accordance with NFPA 96, as required for ventilation control and fire protection of commercial cooking operations. Specifically, a review of the Owners Hood Suppression Inspection form revealed that the facility did not conduct the required monthly inspection for December 2024. This omission was confirmed by the Maintenance Director during the surveyor's review. The deficiency was identified during a record review and interview, and it could affect all occupants in the event of a fire emergency.
Plan Of Correction
Element 1: Hood suppression inspection was not completed in December of 2024. Inspections will be completed monthly. Element 2: All staff of the food and nutrition department have the potential to be impacted. If fire spreads, all residents and staff have the potential to be impacted. Element 3: Hood suppression inspection will be completed monthly and documented as such. Element 4: Physical Plant Manager will be responsible for sustained compliance. Monthly audits will be performed with results to QAPI.
Failure to Transmit Fire Alarm Signal During Third Shift Drills
Penalty
Summary
The facility failed to conduct fire drills in accordance with requirements outlined in 19.7.1.4 through 19.7.1.7. Specifically, during a review of records for the past 12 months, it was found that fire drills conducted on the third shift (11pm-7am) did not ensure that the alarm signal was transmitted to the fire alarm company within a reasonable timeframe. This deficiency was confirmed by the Maintenance Director during the surveyor's review. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Element 1: Failure to ensure the alarm signal was transmitted to the fire alarm company within a reasonable time frame. Audible alarm will be used during all drills. Element 2: All occupants have the potential to be impacted by this deficient practice. Element 3: Physical Plant Manager instructed night shift maintenance person responsible for the drills to use audible alarm on 06/03/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance. Audits will be done quarterly and brought to QAPI.
Failure to Perform Required Generator Battery Testing
Penalty
Summary
The facility failed to conduct required specific gravity or conductance testing of the generator batteries during several months, specifically in May 2024 and from July 2024 through the time of the survey. This omission was identified during a record review on May 19, 2025, and was confirmed by the Maintenance Director at the time of discovery. This deficiency indicates that the facility did not adhere to the maintenance and testing protocols for emergency power systems as outlined in NFPA 110, NFPA 99, NFPA 111, and NFPA 70. The lack of documented battery testing could affect all occupants in the event of a power failure, as the reliability of the generator or alternative power source could not be assured.
Plan Of Correction
Element 1: Facility failed to ensure generator battery was tested for specific gravity. Battery was replaced 06/04/2025 which allows for specific gravity measurement. Element 2: All occupants have the potential to be impacted in the event of power loss. Element 3: Battery was replaced 06/04/2025 which allows for specific gravity measurement. Reading was in compliance on 06/04/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance. Audits will be done monthly and brought to QAPI.
Missing Required Signage on Delayed Egress Door
Penalty
Summary
A deficiency was identified when surveyors observed that the door from the solarium into the 600 wing, which serves as a posted exit, was equipped with 15-second delayed egress hardware. This door did not display the required signage stating, "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS," as mandated by NFPA 101, 7.2.1.6.1.1 (4). The absence of this signage was confirmed during the survey by the Maintenance Director at the time of discovery. The report specifies that the facility failed to ensure that doors in a required means of egress were not equipped with a latch or lock requiring the use of a tool or key from the egress side, unless the special locking arrangements for clinical needs were met according to regulatory standards. This deficiency was noted to potentially affect all occupants in the solarium in the event of a fire or emergency, as the required egress signage and compliance with special locking arrangements were not in place.
Plan Of Correction
Element 1: 600 wing exit needed a PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS sign. Signs were placed on the door on 06/03/2025. Element 2: All residents in the solarium/staff/visitors have the potential to be impacted by this deficiency. Element 3: Sign was placed on the door on 06/03/2025 stating PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. Element 4: Physical Plant Manager will be responsible for sustained compliance.
Exit Signage Not Properly Displayed and Labeled
Penalty
Summary
During an observation on May 19, 2025, it was found that door 8, which leads to the exterior of the building in the 700 wing, was not properly posted as an exit. The door could be mistaken for an exit, but lacked the required signage in accordance with section 7.10.8.3, which mandates a sign stating 'NO EXIT' for doors that are not exits. This deficiency was confirmed by the Maintenance Director at the time of discovery. The report notes that exit and directional signs were not displayed as required, nor were they continuously illuminated and served by the emergency lighting system, as specified by 19.2.10.1.
Plan Of Correction
Element 1: 700 wing door did not have NO EXIT required signage. Signs were placed on the door on 06/03/2025. Element 2: All residents on the 700 wing/staff or visitors have the potential to be impacted by this deficiency. This deficient practice could cause someone to use this door as an exit. Element 3: Signage was placed on the door on 06/3/2025 stating NO EXIT. Element 4: Physical Plant Manager will be responsible for sustained compliance.
Expired Smoke Detectors Remain in Service
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained according to an approved program in compliance with NFPA 70 and NFPA 72. During an observation and record review, it was found that battery-operated smoke detectors installed in resident rooms on the 500 and 600 wings had exceeded their 10-year lifespan, with manufacture dates of May 17, 2001, yet remained in service. This was confirmed during a physical inspection of the devices and verified by the Maintenance Director at the time of discovery. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Element 1: Resident room smoke detectors on 500/600 went beyond their 10-year life span. Unrequired room smoke detectors will be removed, as hallway smoke detectors connected to fire system are sufficient under the requirement. Element 2: There are hallway smoke detectors in these units that are connected to the building fire system. Without them, all residents, visitors, and staff of the 500/600 units would be impacted. Element 3: The battery-operated smoke detectors that are in individual resident rooms will be removed by 06/30/2025, as individual room smoke detectors are not required. Element 4: The Physical Plant Manager will be responsible for sustained compliance.
Improper Use of Sprinkler Pipe for Mechanical Support
Penalty
Summary
A deficiency was identified when, during an observation in the 300 wing mechanical room, a hot water pipe was found being supported and hanging from a sprinkler pipe. This setup was not in accordance with NFPA 13, the Standard for the Installation of Sprinkler Systems, which requires that sprinkler systems be installed as specified and not used to support other building systems. The Maintenance Director confirmed this finding at the time of discovery. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Element 1: Hot water pipe was supported and hanging from sprinkler pipe. Hot water pipe will be removed from sprinkler pipe and supported from ceiling. Element 2: All residents/visitors/staff of the 300 wing have the potential to be impacted by this deficient practice in the event of need for sprinkler use. Element 3: On 06/03/2025 the hanger was removed from the sprinkler pipe and the hot water pipe was secured directly to the ceiling. Element 4: Physical Plant Manager will be responsible for sustained compliance.
Failure of Corridor Doors to Achieve Positive Latch
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors protecting corridor openings were capable of resisting the passage of smoke as required by NFPA 19.3.6.3. Specifically, during an inspection, it was found that the vestibule doors leading to the courtyard from both the 500 and 600 wings did not close to a positive latch. This deficiency was identified through direct observation between 1:29 PM and 1:52 PM on May 19, 2025. The Maintenance Director confirmed at the time of discovery that the vestibule doors did not meet the required standard for positive latching. The report does not mention any specific residents or their medical conditions in relation to this deficiency. The finding was limited to the physical condition and operation of the doors in the specified wings.
Plan Of Correction
Element 1: Doors to the courtyard from the 500 and 600 wings failed to close a positive latch. Physical plant manager contacted multiple vendors and latching hardware will be installed. Element 2: This deficient practice has the potential to impact all occupants of the 500 and 600 wings in the event of a fire. Element 3: Superiorland Electronics will install latching hardware by 07/16/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance. Audits will be done monthly and brought to QAPI.
Smoke Barrier Doors Failed to Fully Close
Penalty
Summary
During an observation conducted on May 19, 2024, at approximately 1:11 PM, it was found that the main entrance cross corridor smoke barrier doors did not fully close as required by the Life Safety Code (LSC). The doors are intended to be 1-3/4-inch thick solid bonded wood-core or of equivalent fire-resistant construction, and must be self-closing or automatic-closing to maintain the integrity of the smoke barrier. The failure of these doors to completely close was confirmed at the time of discovery by the Maintenance Director. This deficiency could potentially affect 20 occupants in the event of a fire, as the doors did not meet the required standards for smoke barrier subdivision.
Plan Of Correction
Element 1: Doors in the entry hallway failed to completely close. Doors and air flow were adjusted for complete closure. Element 2: This deficient practice has the potential to impact the 20 staff near those doors in the event of a fire. Element 3: On 06/03/2025, Automated Comfort Controls were at the facility readjusted the air flow to allow for complete closure of fire doors. Element 4: Physical Plant Manager will be responsible for sustained compliance. Audits will be done weekly x 8 weeks then monthly and brought to QAPI.
Failure to Test and Repair Hospital-Grade Electrical Receptacles
Penalty
Summary
The facility failed to ensure that hospital-grade electrical receptacles at patient bed locations and areas where deep sedation or general anesthesia is administered were tested after initial installation, replacement, or servicing, as required by NFPA 99. During a record review, it was found that multiple outlets in resident rooms throughout the building failed inspection in 2024, and there was no documentation or evidence provided to show that these outlets were repaired or replaced. This deficiency was confirmed by the Maintenance Director at the time of discovery. No information was provided regarding the specific medical history or condition of the residents affected at the time of the deficiency.
Plan Of Correction
Element 1: Multiple outlets in resident rooms failed inspection and documentation did not indicate repair or replacement. Documentation now includes date and type of corrective action. Element 2: This deficient practice has the potential to impact the 30 residents near those outlets in the event of a fire. Element 3: Physical Plant Manager instructed maintenance personnel to document the date and type of corrective action on 06/03/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance. Audits will be done monthly and brought to QAPI.
Failure to Address Prolonged Nausea and Vomiting
Penalty
Summary
The facility failed to develop a care plan and offer or recommend diagnostic testing or consultation with a Gastroenterologist or Physician Specialist to determine the source of prolonged nausea and vomiting for one resident. This deficiency resulted in the resident sustaining a 27.3% weight loss over six months, a decline in activities of daily living (ADL), a significant change of condition, and the development of multiple pressure injuries. The resident was admitted to the facility and was documented as requiring staff assistance for ADLs, with a BIMS score indicating cognitive intactness. Despite numerous progress notes documenting the resident's nausea and vomiting, the care plan did not address these issues, nor was there any indication that the weight loss was desirable by the resident. The medical record revealed significant weight loss and numerous instances of nausea and vomiting documented over several months. Despite these ongoing issues, there was no documentation of any discussion with the resident regarding diagnostic testing or consultation with a specialist. The physician's visit notes from several months did not include plans to address the nausea or offer diagnostic testing. The resident's care plans did not contain interventions for nausea and vomiting, and the medical record did not reveal any discussion with the resident about consulting a specialist or obtaining diagnostic testing. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) Supervisor confirmed awareness of the resident's recurrent nausea and vomiting but revealed that diagnostic testing or specialist consultation had not been discussed with the resident. The resident expressed frustration with the prolonged nausea and vomiting and indicated that the physician had only recently offered to conduct testing. The physician admitted to not knowing the cause of the nausea and vomiting and acknowledged that the resident had declined further testing or consultations only on the day of the interview. The facility policy on significant change notification was not followed, as the Medical Director was not made aware of the prolonged nausea and vomiting experienced by the resident.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to implement and maintain interventions to prevent the development and progression of pressure ulcers for two residents. Resident #62 was admitted with no pressure ulcers but developed multiple stage II pressure ulcers during their stay. Despite being at risk for pressure ulcers, the resident's care plan interventions were not effectively implemented. Observations revealed that the resident's wheelchair was not suitable, and the Roho cushion was deflated, contributing to the development of pressure ulcers. Interviews with the occupational and physical therapists confirmed that the wheelchair was not a good fit and that the cushion was not properly inflated. The resident's progress notes indicated the development and worsening of pressure ulcers, but no changes were made to the care plan interventions to address these issues. Resident #113 was admitted with existing pressure ulcers, which worsened during their stay. The resident's wounds showed signs of infection and progression to a stage IV ulcer. Despite these changes, there was no timely physician follow-up or wound care consultation. The wound care treatment coordinator made multiple attempts to contact the physician for a wound care consultation, but there was no response. The delay in obtaining a wound care consultation resulted in a 14-day lapse from the initial request to the actual consultation. The facility's policies on significant change notification and skin integrity program were not followed, leading to inadequate management of the resident's worsening wounds. The deficiency in pressure ulcer care for both residents highlights a failure in the facility's implementation and maintenance of appropriate interventions. The lack of timely physician follow-up and inadequate communication within the interdisciplinary team contributed to the worsening of the residents' conditions. The facility did not adhere to its policies, resulting in delayed treatment and progression of pressure ulcers for the affected residents.
Failure to Update Care Plans for Fall Prevention
Penalty
Summary
The facility failed to implement, update, and revise comprehensive care plans to prevent falls for three residents, resulting in falls with major injuries. Resident #26, who had a history of falls and a high fall risk score, fell and sustained a left femur fracture. Despite her high risk, the facility did not initiate or document appropriate fall interventions upon her return from the hospital. The Director of Nursing (DON) acknowledged that the facility's fall watch program was not properly implemented for this resident. Resident #9, who had moderate cognitive impairment and multiple diagnoses, fell and sustained a skin tear. The care plan for this resident was not updated to include interventions to prevent further falls. The DON confirmed that the care plan was not revised after the fall, and the RN/Rehab Coordinator stated that falls caused by a urinary tract infection were not typically updated in the care plan. Resident #29, who had intact cognition and multiple diagnoses, experienced multiple falls without any interventions being added to the care plan. The resident fell on three separate occasions, and each time, the care plan was not updated to include fall prevention measures. The DON and RN/Rehab Coordinator both acknowledged that changes were noted in the resident's records but were not reflected in the care plan. The facility's policy on fall risk management was not followed, leading to inadequate monitoring and prevention of falls for these residents.
Failure to Provide Dignified ADL Care
Penalty
Summary
The facility failed to provide activities of daily living (ADL) care in a dignified manner to a resident (R17). On 6/3/24 at 3:10 PM, a CNA was observed assisting R17 to the bathroom. Subsequently, R17 was left unattended on the toilet with both the bathroom door and the room door open. This lack of privacy was further compromised when another resident (R57) entered R17's room in a wheelchair. CNA G redirected R57 out of the room but acknowledged that the door should have been partially closed to prevent such incidents, especially since R17 is a fall risk. CNA D admitted to leaving R17 unattended with the doors open because he needed to retrieve a brief and did not seek assistance. He acknowledged that R17 did not have privacy and that he should have handled the situation differently. The Nursing Home Administrator confirmed that staff are expected to close doors to provide privacy and prevent wandering residents from entering rooms. The failure to close the doors resulted in a breach of R17's dignity and privacy while using the bathroom.
Latest citations in Michigan
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
