Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Optalis Health And Rehabilitation Of Three Rivers during CMS and state inspections, most recent first.
DON Not Working Full Time as Required: The facility failed to ensure the DON of record worked full time for three weeks. DON B was listed as the DON of record but worked only a few hours in the first two weeks and no hours in the third week, while staff instead directed clinical concerns, falls, staffing issues, and urgent needs to an LPN and, at times, a regional clinical director. Multiple staff stated there was no full-time DON in the building until the DON began working full time.
A resident with Alzheimer’s disease, depression, severe protein calorie malnutrition, and severe cognitive impairment was not able to have favorite foods brought by family reheated as requested. The family was told to bring only shelf-stable foods or heat the food themselves, while staff reported they were instructed not to reheat resident food and only to use the microwave for popcorn, despite the facility’s written outside food policy allowing safe reheating.
Failure to revise fall care plans after resident falls. Two residents had documented falls and related changes in condition, but their care plans were not updated with new interventions. One resident with a history of fractures and repeated falls had an enabler bar listed in the care plan without a corresponding order, and the bed was observed without the bar in place; after a later fall with head injury and hospital transfer, no fall report or new interventions were documented. Another resident with CVA-related weakness and impaired cognition fell out of bed, but the fall report and care plan did not reflect any new interventions despite IDT discussion.
Incomplete Bowel and Bladder Documentation: The facility failed to maintain complete and accurate medical records for a resident with Alzheimer’s disease, depression, severe protein calorie malnutrition, and severe cognitive impairment. The care plan called for toileting assistance with a 2-person sit-to-stand mechanical lift, but bowel and bladder documentation was incomplete across multiple months, and the DON acknowledged the gaps in documentation.
A resident with dementia and a history of wandering was pushed by another resident with paranoid schizophrenia and aggressive behaviors after entering the latter's room, resulting in a hip fracture that required surgery. The incident occurred despite documented histories of wandering and aggression, and staff reports of feeling unsafe around the aggressive resident. Care plans included general interventions for wandering and behavior, but there was no evidence of targeted supervision or measures to prevent such altercations.
A resident with severe cognitive impairment was transferred to the hospital for a femoral neck fracture, but the facility did not provide a written bed hold notice to the resident's representative or document any follow-up communication in the medical record. Staff interviews revealed inconsistent practices, and the responsible party reported not being informed about the bed hold policy, contrary to facility policy requirements.
A resident with severe dementia was abruptly discharged to a locked memory care unit without adequate individualized interventions or proper notice, despite manageable behaviors and established routines that supported his well-being. The facility failed to implement new strategies to address concerns about interactions with other residents and did not provide the resident's representative with an opportunity to appeal the discharge. After the transfer, the resident experienced increased anxiety, agitation, and required additional psychotropic medications.
A resident with severe dementia was subjected to repeated verbal threats, insults, and mocking by another cognitively intact resident with a history of mental health issues. Staff, including the DON and NHA, were aware of the ongoing abuse but did not conduct an investigation or implement interventions to protect the targeted resident, despite the facility's abuse policy defining such actions as abuse.
Staff observed and reported that a cognitively intact resident engaged in repeated verbal aggression and bullying toward a resident with severe cognitive impairment, including threats and mocking in common areas. Multiple staff, including CNAs and an activity aide, reported these incidents to the DON and NHA, but the facility did not consider the actions to be abuse and failed to report the allegations to the State Agency as required by policy.
Two residents were involved in a situation where one, who was cognitively intact, verbally threatened another resident with severe cognitive impairment. Staff and a family member reported ongoing verbal threats and targeting of the cognitively impaired resident, but the DON and NHA did not conduct a thorough investigation as required by facility policy, failing to interview all involved or obtain written statements.
A resident with severe cognitive impairment and dementia was discharged without proper written notification to their DPOA. The DPOA was only informed by phone of the need to transfer the resident and was not given information about the right to appeal or the voluntary nature of the discharge, contrary to facility policy requiring written notice and explanation of appeal rights.
Two residents with behavioral and cognitive needs did not have individualized, person-centered care plan interventions reflecting their current conditions. One resident with anger management issues and another with severe cognitive impairment and wandering behaviors were not properly monitored or had their care plans updated, despite staff and family awareness of their needs.
The facility failed to provide medically related social services for two residents, resulting in a lack of advocacy for one resident's rights and insufficient individualized behavior management and discharge planning for both. One resident with dementia was transferred without proper interventions or documentation, while another resident with mental health diagnoses made threats without specific care plan updates. The absence of a dedicated social worker contributed to these deficiencies.
The facility did not maintain accurate and complete medical records for two residents, failing to document significant behavioral incidents, monitoring needs, and discharge notifications. Staff interviews revealed unrecorded behavioral issues and wandering, while care plans and monitoring reports did not reflect these events. Required written discharge notification was also not provided or documented for one resident.
The facility failed to ensure that residents were protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to insufficient protective measures and oversight.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their documented preferences and goals, resulting in care that was not individualized as required.
A resident did not receive the medically-related social services needed to support their highest possible quality of life, as required by regulations.
A resident with severe cognitive impairment was found restrained in a wheelchair with a gait belt, contrary to her care plan, at a nurse's station. Staff interviews revealed that an LPN placed her there to prevent falls, but denied using a gait belt. The resident identified the LPN as the one who restrained her, leading to a deficiency citation for unauthorized restraint use.
The facility failed to prevent the misappropriation of narcotic medications for two residents. A nurse administered an incorrect dosage of Morphine Sulfate to a resident, using medication from another resident's card. Additionally, a discrepancy in Lorazepam administration was found, with a missing tablet and improper narcotic count verification by night nurses. The facility's policy on controlled medications was not followed, leading to medication errors and potential misappropriation.
The facility failed to document medication administration for two residents, leading to potential issues with controlled substances. A resident received Alprazolam without immediate documentation by an LPN, and another resident's Morphine administration was not recorded by an RN. This lack of adherence to documentation standards was confirmed by the ADON and DON.
A resident with cognitive impairment and a history of depression was hospitalized with aspiration pneumonia after the facility failed to assess and treat his change of condition. Despite complaints of dizziness, fatigue, and lack of appetite, there were no medical evaluations or vital signs documented for several days. The Medical Director was unaware of the resident's symptoms due to a lack of communication and documentation, leading to a delay in appropriate medical intervention.
A facility failed to remove a discharged resident's Morphine from the medication cart, resulting in another resident receiving an incorrect dosage. A nurse mistakenly administered two 30 mg Morphine tablets instead of the prescribed 45 mg, due to using the discharged resident's medication. The error was not fully realized by the DON, and the facility's medication disposal policy was not followed.
A resident with severe cognitive impairment and osteoporosis suffered a femur fracture, which was not reported to the State Agency within the required two-hour timeframe. The injury was discovered during a transfer, and although the physician suspected it might be pathological, there was no documentation to support this, nor was a full investigation conducted to rule out mistreatment. The facility's delay in reporting and lack of investigation highlight deficiencies in their processes.
The facility was cited for multiple deficiencies in food safety and equipment maintenance, affecting 82 residents. Observations revealed severely soiled food service equipment, improper date marking of ready-to-eat foods, and malfunctioning dishwashing equipment. These issues increase the risk of cross-contamination and foodborne illness.
The facility failed to implement comprehensive care plans for six residents, leading to potential unmet needs. A resident's smoking supplies were not secured as per policy, and another resident's fall risk intervention was not followed. Additionally, four residents with COVID-19 lacked care plans for isolation and infection management, despite precautions being indicated. Staff interviews revealed gaps in policy awareness and communication.
The facility failed to provide consistent showers and bathing to several residents, leading to unmet personal hygiene needs. A resident with multiple health issues did not receive scheduled showers due to a COVID outbreak, while another was left with long toenails and soaked in bed due to inadequate toileting assistance. A double amputee reported not receiving showers during isolation, and a cognitively intact resident experienced infrequent bed baths and inadequate hair washing. Staffing shortages and mismanagement were cited as reasons for these deficiencies.
The facility experienced significant staffing shortages, particularly on weekends, leading to unmet care needs for residents. Despite using agency staff and management covering shifts, the facility struggled to maintain adequate staffing levels. Residents reported not receiving showers, and staff confirmed that care tasks were incomplete due to insufficient staff. The administration was aware of the issue, but the lack of proper training for new staff and consistent call-ins exacerbated the problem.
The facility did not complete annual competency evaluations for three CNAs, potentially leading to unmet resident care needs. Evaluations were conducted electronically, with the DON responsible for completion. Notifications were sent to the DON and CNAs, but one evaluation was not completed, and two were not acknowledged by the CNAs.
The facility failed to secure medications in two of four medication carts, as observed on multiple occasions. The C Hall cart was found unlocked and unattended twice, with Agency RNs on their first day responsible. The A Hall cart was also found unlocked and unattended, violating the policy to lock carts when not in direct view of the administering nurse.
The facility failed to implement effective infection control measures, leading to potential cross-contamination and the spread of COVID-19. Observations showed inadequate signage and PPE availability, with staff not consistently adhering to PPE protocols. Specific incidents included staff entering COVID-positive rooms without proper PPE, contributing to infection risks. Residents with complex medical histories were affected, highlighting the facility's failure to maintain Enhanced Barrier Precautions.
The facility failed to maintain a clean and safe environment, affecting 82 residents. Observations revealed soiled areas, missing safety features, and multiple maintenance issues in common areas and resident rooms. The facility's maintenance and cleaning policies were not adhered to, with no work orders addressing these concerns. Additionally, unsmoothed spackling and a bare mattress were noted in a resident room.
The facility failed to promote dignity and respect for two residents, leading to potential feelings of diminished self-worth and anxiety. A resident with severe cognitive impairment was observed in a state of undress and without meal assistance, compromising his dignity. Another resident, on COVID-19 precautions, experienced increased anxiety due to her request to have her room door open being denied, despite her fear of dying alone. The facility's actions and inactions did not adequately address the residents' needs for privacy and emotional support.
A facility failed to assess a resident's ability to self-administer medication, leaving pills at the bedside without proper evaluation. The resident, with multiple health conditions and a BIMS score indicating cognitive intactness, was unsure about her medications. Staff interviews revealed that an assessment was required but not completed, and the care plan lacked necessary documentation. The DON confirmed that no residents were approved to self-administer medications.
Two residents expressed anger and frustration after a facility moved vending machines to an employee break room, restricting resident access. This decision was made due to concerns about dietary adherence, but it affected residents who were cognitively intact and had no dietary restrictions prohibiting vending machine use. Staff interviews revealed a lack of awareness and communication about the decision.
The facility failed to update care plans for two residents after changes in their conditions. One resident's care plan did not reflect current dietary orders and discontinued medication, while another resident's care plan did not address her refusal to have blood sugar checks despite receiving insulin. This resulted in inaccuracies in their care plans, as acknowledged by the DON.
A facility failed to implement and update fall prevention interventions for a resident with a history of falls and medical conditions such as diabetes and stroke. The care plan required the bed to be in a low position, but the resident experienced multiple falls without injury, and no new interventions were added. During an observation, the bed was not in the lowest position, and a CNA was unaware of the resident's need for posey hipsters, indicating non-compliance with the care plan.
A facility failed to offer a pneumococcal vaccine to a resident who was eligible and due for the vaccine upon admission. The resident, who was cognitively intact and had diagnoses of type 1 diabetes, anxiety, and depression, did not have a pneumonia vaccine documented in their immunization records. The Infection Preventionist confirmed that the vaccine was not offered, and there were no signed consents or declination documented. The facility's policy required evaluation and offering of the vaccine upon admission, with informed consent to be documented, which was not followed in this instance.
The facility failed to offer COVID-19 vaccinations to three residents, increasing the risk of severe infection. A resident with a history of heart failure requested a booster for months but did not receive it, leading to severe symptoms after testing positive. Two other residents, both cognitively intact, were not offered the vaccine upon admission, with no documentation of consent or declination. The facility's policy to offer and document COVID-19 vaccinations was not followed.
The facility failed to ensure a CNA completed the required 12-hours of annual in-service training, potentially leading to unmet resident care needs. The HR/P representative and Clinical Coordinator confirmed that department managers were responsible for tracking training completion, but documentation for one CNA was missing, indicating non-compliance with training requirements.
A resident experienced anger and frustration due to a delay in mail delivery caused by the previous administrator's failure to sort and distribute mail on time. The mail was locked in the administrator's office for several days, delaying the resident's receipt of a package. The issue was resolved after the administrator's departure, with daily mail delivery resuming.
The facility was found to have multiple safety and sanitation issues, including broken tiles, soiled ventilation screens, peeling flooring, and exposed sharp edges. Staff interviews revealed resident complaints about cleanliness, and the need for environmental improvements was acknowledged by the staff, including the DON and Maintenance Director.
A resident with moderate cognitive impairment and a history of heart and lung conditions was unable to access $80 from her trust account to pay important bills, causing her anxiety and frustration. The facility, lacking a full-time Business Office Manager, struggled to maintain enough cash for resident withdrawals, leading to the denial of the resident's request. The facility's policy required withdrawals to be available within three working days, which was not met.
A resident's lock box containing $152 was lost due to the facility's failure to prevent misappropriation of property. Despite having a care plan that included a lock box for safekeeping, the resident's money went missing, leading to feelings of frustration and helplessness. The resident expressed concerns about the security of her belongings, affecting her trust in the facility and her overall well-being. Investigations by the facility and police did not identify a suspect.
DON Not Working Full Time as Required
Penalty
Summary
The facility failed to ensure the Director of Nursing (DON) of record worked full time, defined as 40 hours per week, for three weeks from 3/2/2026 through 3/22/2026. Interview and record review showed DON B was listed as the DON of record beginning 3/3/2026, but she did not start working full time in the facility until 3/23/2026. Her timesheet showed she worked only 6.5 hours during the week of 3/2/2026 to 3/8/2026, 6.63 hours during the week of 3/9/2026 to 3/15/2026, and no hours during the week of 3/16/2026 to 3/22/2026. During this period, staff reported clinical and administrative concerns to Agency LPN FF and, at times, to Regional Clinical Director OO, rather than to a full-time RN DON in the building. Multiple staff members stated that LPN FF was acting as the interim DON or contact person for clinical needs, falls, staffing issues, incidents, and urgent concerns, even though she stated she could not act as DON because she was not an RN. A posted notice directed staff to call LPN FF for clinical on-call needs, and the Nursing Home Administrator acknowledged that DON B did not work 40 hours per week during the three-week period.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident’s preferences regarding heating and reheating favorite foods brought in by family. The resident was admitted with Alzheimer’s disease, depression, and severe protein calorie malnutrition, and the MDS showed a BIMS score of 2 out of 15, indicating severe cognitive impairment. The resident later started hospice care and was discharged from the facility. The family member reported that the former NHA told them to bring only shelf-stable foods or foods they could heat themselves, and not to bring foods that needed to be reheated unless they were present to do it, because the NHA did not trust facility staff to heat and serve the meals. The RD stated the resident had a slow decline for months and weight loss, and the team was working with the family to get the resident favorite foods on meal trays and nutritional supplements to prevent further weight loss. Staff interviews showed they had been told they could not heat or reheat resident foods, with one CNA stating they could only make popcorn in the breakroom and did not know why food could not be warmed in the kitchen. The corporate RD stated outside food was not allowed in the kitchen and could be reheated in the break room, while the NHA and an agency LPN later stated residents should be able to have foods heated safely and that staff should take food to the kitchen for temperature checks. The facility’s Outside Food Policy stated the facility would accommodate storing outside food and reheating it safely, but staff practice and instructions to the family conflicted with that policy.
Failure to Revise Fall Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise the care plans for two residents after falls and related changes in condition. For one resident, the record showed a history of falling, muscle weakness, prior femur and cervical vertebrae fractures, and a BIMS score of 13 indicating cognitive intactness. After a fall on 2/9/2026, the interdisciplinary team documented that the resident continued to fall out of bed and was non-compliant with fall interventions, and an enabler bar was ordered as an immediate intervention. However, the resident’s care plan listed the enabler bar as an intervention even though no order was found for it, and an observation later showed the bed did not have enabler bars in place. The same resident had another fall on 3/15/2026, when he was found face down on the floor with a large hematoma on the right forehead, another raised scalp contusion, sluggish pupils, upward right gaze, and delayed responses before being transported to the hospital. There was no fall report for this event, and no new interventions were added after the fall. An LPN stated the agency nurse who documented the progress note did not call about the fall, the agency nurse was not allowed back in the building, and the resident returned from the hospital without the IDT discussing the fall or interventions. A second resident, with diagnoses including depression, anxiety, and hemiplegia/hemiparesis following cerebral infarction, had a BIMS score of 9 indicating moderately impaired cognition. After being found sitting on the floor on 3/9/2026, the resident was assessed and assisted back to bed, but the fall report did not include any new interventions and the care plan was not updated. An LPN stated the resident had fallen out of bed while reaching for his urinal and that the team discussed interventions in IDT, but no intervention was entered into the care plan and no progress note documented the discussion.
Incomplete Bowel and Bladder Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for bowel and bladder care for one resident who was admitted with Alzheimer’s disease, depression, and severe protein calorie malnutrition. The resident had a BIMS score of 2 out of 15, indicating severe cognitive impairment, and later started hospice care before discharge from the facility. The care plan identified an ADL self-care deficit related to Alzheimer’s dementia and included toileting assistance with a 2-person sit-to-stand mechanical lift. Record review showed incomplete documentation of the resident’s bowel and bladder status. The documentation survey report reflected that bladder elimination was documented 42 of 93 opportunities in December, 36 of 93 in January, and 19 of 53 in February, while bowel elimination was documented 43 of 93 opportunities in December, 34 of 93 in January, and 20 of 53 in February. During interview, the resident’s family member stated the resident was dependent for ADLs and needed help using the bathroom, and the DON stated she was aware of the holes in documentation.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to ensure adequate supervision to prevent resident-to-resident abuse, resulting in a resident with dementia and severe cognitive impairment being pushed by another resident with a history of paranoid schizophrenia, delusions, hallucinations, and aggression. The incident occurred when the cognitively impaired resident, who had a documented history of wandering and entering other residents' rooms, was found on the floor outside the aggressive resident's room after being pushed. The injured resident sustained a closed left femoral neck fracture, requiring surgical intervention and a subsequent decline in functional status, now needing assistance with activities of daily living and ambulation. Prior to the incident, the resident with dementia was known to wander independently throughout the facility and had been documented as entering or lingering near other residents' rooms on multiple occasions. The care plan for this resident included interventions for wandering and cognitive impairment, but these primarily focused on redirection, encouragement to attend activities, and non-pharmacological interventions. Staff interviews revealed that the resident required frequent reminders not to enter other residents' rooms due to her memory deficits, and that she did not regularly participate in group activities, preferring to spend time alone. The resident who pushed the other had a well-documented history of delusions, paranoia, and aggressive behaviors, including previous incidents of threatening staff, refusing care, and expressing fears of being harmed or poisoned. Staff and behavioral logs indicated that this resident had exhibited threatening and unpredictable behavior on several occasions, and some staff reported feeling unsafe when providing care. Despite these known risks, there was no evidence of enhanced supervision or specific interventions to prevent resident-to-resident altercations between these two individuals prior to the incident.
Failure to Provide and Document Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to the resident's representative when the resident was transferred to the hospital, and did not document any follow-up communication or attempts in the resident's medical record. The resident, who had dementia and severe cognitive impairment, was transferred to the hospital for a femoral neck fracture requiring surgery. Interviews with facility staff revealed inconsistent practices regarding the distribution and documentation of bed hold notices, with some staff stating that the notice is sent with the resident and others indicating that follow-up calls are made to the responsible party. However, there was no evidence in the resident's chart of a bed hold notice being provided or any follow-up attempts documented. The facility's own policy requires that upon a resident's transfer for hospitalization, written notice specifying the bed hold policy must be provided to the resident and their representative, and that attempts to contact the representative and their decision regarding the bed hold must be documented in the resident's record. In this case, the responsible party reported not being informed about the bed hold policy at the time of transfer, and the facility was unable to provide documentation that the required notice or follow-up occurred. This resulted in the potential for the resident and/or their representative to be uninformed about the bed hold policy during the hospital transfer.
Failure to Prevent Unnecessary and Abrupt Discharge of Resident with Dementia
Penalty
Summary
The facility failed to prevent an unnecessary and abrupt discharge of a resident with dementia, resulting in significant emotional distress and increased behavioral symptoms. The resident, who was severely cognitively impaired and had a history of dementia with behavioral disturbances, was familiar with the facility environment and had established routines that helped manage his anxiety and agitation. Despite this, the facility's interdisciplinary team, including the Nursing Home Administrator and Director of Nursing, decided to seek a transfer for the resident due to concerns about his wandering and interactions with other residents, particularly after another resident verbally threatened him. However, the only intervention implemented was increased staff supervision as available, and there was no evidence of individualized care or additional interventions to address the situation within the facility. Interviews with staff indicated that the resident's behaviors were manageable and that he was easily redirected. The care plan included strategies such as involving the resident in one-on-one activities and maintaining a predictable routine, but there was no documentation of new or enhanced interventions to address the reported concerns. The resident's representative was not given the option to appeal the discharge and was only informed of the transfer on the day it occurred. The facility did not provide documentation of efforts to address the behaviors of the other resident who was threatening the discharged resident, nor did they pursue additional resources or support due to the absence of a social worker at the time. Following the abrupt transfer to a locked memory care unit, the resident experienced increased anxiety, agitation, and emotional distress, requiring pharmacological intervention. Reports from the receiving facility and the resident's representative indicated that the resident became physically aggressive, more combative, and required multiple psychotropic medications to manage his intensified behaviors. The facility's discharge policy required specific documentation and notice, including the basis for discharge and efforts to meet the resident's needs, but there was no evidence that these requirements were met. The lack of individualized care and failure to prepare the resident for a safe and appropriate transfer led to significant psychosocial harm.
Failure to Protect Resident from Ongoing Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse, specifically in the case involving two residents. One resident, who was cognitively intact but had a history of borderline intellectual functioning, bipolar disorder, and anxiety, repeatedly directed verbal threats, insults, and mocking toward another resident with severe dementia. Multiple staff members, including the DON and NHA, were aware of these incidents, which included threats of physical harm and derogatory remarks made in public areas of the facility. Staff interviews confirmed that the abusive resident regularly made such statements and that these interactions were ongoing. The resident who was the target of the abuse had severe cognitive impairment due to dementia and was unable to fully express his feelings about the incidents. However, his DPOA and staff noted that he would become emotionally upset if spoken to harshly. The care plan for this resident included interventions for managing anxiety and agitation, but there was no evidence that specific measures were implemented to address the ongoing verbal abuse from the other resident. Staff acknowledged that the abusive behavior was a continuous issue and that the resident with dementia was being targeted, but no formal investigation or documentation of interventions was completed. Despite multiple reports and observations of the abusive behavior, including threats and public humiliation, the facility did not take adequate steps to investigate or prevent further incidents. The DON and NHA both confirmed their awareness of the situation but did not initiate an investigation or implement new interventions to protect the resident with dementia. The facility's own abuse policy defined such verbal threats and mocking as mental and verbal abuse, yet the response from staff was insufficient to ensure the resident's safety and dignity.
Failure to Report Alleged Verbal and Mental Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency involving two residents. One resident, who was cognitively intact and had diagnoses including borderline intellectual functioning, bipolar disorder, and anxiety, was reported by multiple staff members and another resident to have engaged in verbally aggressive and bullying behavior towards another resident with severe cognitive impairment due to dementia. Incidents included yelling, making threats, mocking, and making derogatory comments in the dining room, which were witnessed by several staff members including CNAs, an activity aide, and a nurse. These behaviors were discussed among staff and in interdisciplinary team meetings, but were not taken seriously or escalated as abuse allegations. Staff interviews revealed that the bullying and verbal aggression were reported to both the Director of Nursing (DON) and the Nursing Home Administrator (NHA) at the time of the incidents. Despite these reports, the DON and NHA did not consider the actions to constitute abuse, as there was no physical contact, use of profanity, or apparent harm. As a result, no report was made to the State Agency as required by facility policy and federal regulations, which mandate immediate reporting of all allegations of abuse, including verbal and mental abuse, regardless of perceived severity or outcome. The facility's own policy defined mental and verbal abuse to include harassment, mocking, insulting, ridiculing, yelling, or threatening behavior, and required immediate reporting of such allegations to the administrator and the State Survey Agency. The failure to report these incidents, despite multiple staff being aware and the behaviors fitting the policy's definition of abuse, constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents. One resident, who was cognitively intact and had diagnoses including borderline intellectual functioning, bipolar disorder, and anxiety, verbally threatened another resident in the dining room. This incident was witnessed by an activity aide, who reported it to both the Director of Nursing (DON) and the Nursing Home Administrator (NHA), but was not asked to provide a written statement. The resident who was threatened had severe cognitive impairment due to dementia and other medical conditions. Multiple staff members and a family member reported that this resident was being targeted and verbally threatened by a group of residents, including the resident who made the threat. Despite these reports, the DON and NHA did not conduct a thorough investigation. The DON stated that the information provided did not indicate abuse and therefore did not warrant further investigation. The NHA recalled only a brief, in-the-moment inquiry and did not remember the incident reported by the activity aide. The facility's policy requires investigation of all alleged violations, including interviewing all involved persons and witnesses, but this was not followed. As a result, the potential for the allegation to not be thoroughly investigated and for further abuse to occur remained.
Failure to Provide Written Discharge Notification and Appeal Rights
Penalty
Summary
The facility failed to provide proper written discharge notification to a resident's Durable Power of Attorney (DPOA) during the discharge process. The resident, who had a diagnosis of dementia with behavioral disturbance and was assessed as severely cognitively impaired, was abruptly discharged from the facility. The DPOA reported receiving only a telephone call from the Admissions Coordinator informing her that the resident needed to be transferred to another skilled nursing facility and was instructed to come immediately to transport the resident. The DPOA was not given the option to appeal the discharge and was not informed that the discharge was voluntary. Upon arrival at the facility, the DPOA was told by the Nursing Home Administrator that the resident was being harassed by another resident and had to leave. The Nursing Home Administrator later confirmed that no written notification of discharge, including the rationale for discharge and information about appeal rights, was provided to the DPOA at the time of the resident's discharge. Facility policy requires that such notice be given to both the resident and their representative, including the specific reason for discharge, explanation of appeal rights, and information on how to obtain and submit an appeal form.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, individualized care plan interventions for two residents, resulting in the potential for unmet needs. One resident, a female with borderline intellectual functioning, bipolar disorder, and anxiety, was cognitively intact but reported significant anger management issues, particularly towards another resident. Despite her expressed concerns about her anger and interactions with another resident, the care plan only included general interventions for suspiciousness and did not address her specific behavioral concerns or the recent escalation in her anger. Interviews with staff revealed a lack of awareness and monitoring of her behaviors, and there was no clear documentation or update to her care plan following incidents involving the other resident. Another resident, a male with dementia, a history of stroke, and joint replacement, was severely cognitively impaired and exhibited frequent wandering behaviors. He was known to wander the facility, was easily redirectable, and often entered other residents' rooms due to confusion about his own room location. Family and staff interviews confirmed his wandering as a baseline behavior and a means of stress relief. However, his care plan did not reflect his wandering, inability to locate his room, or his tendency to enter other residents' rooms, despite these behaviors being well-documented in progress notes and staff observations. The deficiency was further evidenced by interviews with various staff members, including CNAs, RNs, and LPNs, who either were unaware of the need to monitor the first resident for behavioral issues or confirmed the second resident's wandering without corresponding care plan interventions. The lack of updated, individualized care plans for both residents demonstrated a failure to ensure that care plans were comprehensive, person-centered, and responsive to the residents' current needs and behaviors.
Failure to Provide Medically Related Social Services and Individualized Behavior Management
Penalty
Summary
The facility failed to provide medically related social services to support the mental and psychosocial health of two residents. One resident with dementia and severe cognitive impairment was subject to a transfer process initiated by the facility's interdisciplinary team due to concerns about his interactions with other residents. The resident's care plan did not include interventions related to wandering or maintaining his safety around other residents who were frustrated by him. Documentation showed no social work interventions, and the resident's representative was not informed of the right to appeal the discharge or that the discharge was voluntary. Staff interviews revealed that interventions to address the resident's behaviors and safety were limited to increased supervision, with no evidence of individualized behavior management or documentation of these actions. Another resident, who was cognitively intact but had a history of borderline intellectual functioning, bipolar disorder, and anxiety, expressed difficulty managing anger and reported making verbal threats toward the first resident. The care plan for this resident included general interventions for suspiciousness and coping but did not address the specific issue of threatening or harassing other residents. Staff interviews indicated that interventions were limited to attempts to keep the residents separated and verbal communication among staff, with no clear documentation or care plan updates regarding these behaviors. During the period in question, the facility did not have a dedicated social worker, and social work responsibilities were handled by nursing staff and a corporate-level social worker who was not involved in the care planning or discharge planning for the affected residents. The lack of social work involvement resulted in insufficient advocacy for residents' rights, inadequate individualized behavior management interventions, and incomplete discharge planning, as evidenced by the absence of documented interventions and care plan updates.
Failure to Maintain Accurate Medical Records and Discharge Documentation
Penalty
Summary
The facility failed to maintain clear and accurate medical records for two residents, resulting in incomplete documentation of behaviors, care needs, and discharge processes. For one resident with a history of borderline intellectual functioning, bipolar disorder, and anxiety, there was no documentation in the medical record regarding a reported yelling incident and ongoing behavioral issues, despite staff interviews indicating repeated behavioral concerns and a care plan that included monitoring for such behaviors. Multiple staff members were either unaware of the need to monitor this resident or reported no behaviors observed, and behavior monitoring reports did not reflect the incidents described by staff. For another resident with dementia and behavioral disturbances, the medical record did not accurately document wandering behaviors, exit-seeking, or the resident's inability to locate his room, even though several staff and family interviews confirmed these behaviors were frequent and escalating prior to discharge. The care plan and behavior monitoring reports failed to include or reflect these significant behaviors, and documentation of wandering was notably absent despite it being an available option in the monitoring system. Additionally, when this resident was discharged due to increased behavioral needs that could not be met at the facility, there was no written notification of discharge provided to the resident's representative, and this documentation was not uploaded into the medical record as required by facility policy. The provider discharge summary also lacked specific details about the behaviors leading to discharge and the rationale for transfer, further contributing to the incomplete and inaccurate medical record.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight. Specific actions or inactions leading to this deficiency are not detailed in the report, nor are particular events or resident conditions described.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required by regulation.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that indicated residents did not receive adequate social services support as required to address their individual needs and promote their well-being.
Unauthorized Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to prevent the use of physical restraint on a resident, identified as Resident #100, who was found confined in a wheelchair with the brakes locked against the nurse's station. The resident, who was severely cognitively impaired with a BIMS score of 5/15, was admitted with diagnoses including unspecified psychosis, vascular dementia, and generalized anxiety disorder. Despite being able to walk independently, the resident was placed in a wheelchair and restrained with a gait belt, which was not part of her care plan. On the night of the incident, LPN S discovered Resident #100 restrained in a wheelchair and emotionally upset, unable to remove the gait belt. LPN S reported the situation to DON B, who instructed her to release the resident and conduct a skin and pain assessment. Interviews with staff revealed that LPN Z had placed the resident in the wheelchair to prevent falls, but denied using a gait belt. CNA E and CNA H also provided accounts of the resident's restlessness and the challenges in supervising her due to staffing constraints. The investigation summary indicated that Resident #100 identified LPN Z as the person who placed the gait belt on her. Despite the resident's cognitive impairments, the report suggests that any reasonable person would experience emotional distress from being physically restrained. The facility's failure to adhere to the resident's care plan and prevent the use of unauthorized restraints resulted in a deficiency citation.
Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to prevent the misappropriation of scheduled narcotic medication for two residents, resulting in the potential for ongoing misappropriation of narcotic medications. For one resident, a nurse mistakenly administered a 30 mg Morphine Sulfate tablet from another resident's medication card, who had been discharged from the facility. This resulted in the resident receiving an incorrect dosage of 60 mg instead of the prescribed 45 mg. The nurse involved acknowledged the error and reported it to the supervisor, but the Director of Nursing (DON) did not conduct a further investigation into the medication misappropriation. In another incident, a discrepancy was found in the administration of Lorazepam for a different resident. The Controlled Drug Receipt/Record/Disposition Form indicated that a tablet was missing, and the DON's investigation revealed that two night nurses did not appropriately verify the narcotic count before administering medication. A pill resembling Lorazepam was found under the narcotic drawer, but it was not confirmed if it was the missing medication. The facility's policy on controlled medications was not followed, as the narcotic count was not consistently verified by the nurses involved. The facility's policy requires a physical inventory of all controlled medications to be completed by two licensed nurses, but this was not adhered to. The report highlights that the night nurses shared a medication cart and narcotic drawer, which led to confusion and lack of accountability. The failure to follow proper procedures for handling and documenting controlled substances resulted in medication errors and potential misappropriation, as evidenced by the discrepancies in the narcotic counts and administration records.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to adhere to nursing professional standards related to the documentation of medication administration for two residents, resulting in potential issues with controlled substances and medication accuracy. Resident #206, who was cognitively intact and had a history of anxiety disorder, was observed to have received Alprazolam at noon on April 2, 2025. However, the LPN responsible for administering the medication did not document the administration on the disposition form at the time of administration, as confirmed by the Assistant Director of Nursing. This lapse in documentation is against the standard practice of signing out medications immediately after administration. Similarly, for Resident #110, the facility failed to document the administration of Morphine Sulfate Oral Solution on the Medication Administration Record, despite the medication being signed out by an agency RN on multiple occasions. The RN confirmed that the medication was not documented as administered, and the Director of Nursing reiterated the importance of documenting medication administration in the Medication Administration Record to confirm it was given. The facility's policy on controlled medication guidelines requires documentation of both the removal and administration of controlled medications, which was not adhered to in these instances.
Failure to Assess and Treat Resident's Change of Condition
Penalty
Summary
The facility failed to comprehensively assess and prescribe appropriate treatment for a resident who was hospitalized with aspiration pneumonia. The resident, who was moderately cognitively impaired and had a history of major depressive disorder, reported symptoms such as vertigo, dizziness, fatigue, and lack of appetite. Despite these complaints, there was no documentation of medical evaluations, nursing assessments, or vital signs recorded for the resident between January 21 and January 27, 2025. Interviews revealed that the resident had expressed feeling unwell to several staff members and had episodes of vomiting and coughing, which were not communicated to the Medical Director. The Medical Director admitted to being behind on documentation and was unaware of the resident's coughing during meals, a potential indicator of aspiration risk. The resident was eventually sent to the hospital for a psychiatric evaluation but was admitted for medical reasons due to pneumonia and other acute conditions. The facility's Change of Condition policy requires staff to notify a licensed nurse of any significant deviations from a resident's baseline condition. However, the lack of communication and documentation led to a failure in recognizing and addressing the resident's medical needs, resulting in hospitalization for aspiration pneumonia and other acute illnesses.
Failure to Properly Dispose of Discharged Resident's Medication Leads to Error
Penalty
Summary
The facility failed to properly remove and dispose of controlled substance medication for a discharged resident, leading to a medication error. A resident, who was discharged, had their Morphine sulfate ER 30 mg tablets left in the medication cart instead of being removed and stored securely. This oversight resulted in another resident receiving an incorrect dosage of Morphine. Specifically, a nurse mistakenly administered two 30 mg Morphine tablets to a resident instead of the prescribed 45 mg, due to pulling a 30 mg dose from the discharged resident's medication card. The error was compounded by the fact that the nurse did not realize the mistake until after the medication was administered, and the Director of Nursing (DON) was unaware of the full extent of the error. The resident who received the incorrect dosage was experiencing pain from a pressure ulcer and continued to request additional pain medication. The facility's policy on medication disposal was not followed, as the discharged resident's medication was not promptly removed from the cart and stored in the medication room safe, leading to the potential for diversion or misappropriation.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure the timely identification and reporting of an injury of unknown origin for a resident, resulting in a potential risk for unidentified abuse or neglect. The resident, a female with severe cognitive impairment and a history of osteoporosis and vascular dementia, was found to have a fracture in her left femur. The injury was discovered when the resident complained of pain during a transfer to bed, and an X-ray confirmed the fracture. Despite the facility's policy requiring immediate reporting of such incidents, the injury was not reported to the State Agency within the required two-hour timeframe. The incident was initially reported by a nurse to the Director of Nursing (DON) in the evening, who then contacted the physician. The physician suspected the fracture might be pathological due to the resident's medical history, and this was communicated to the DON. However, there was no documentation in the resident's medical record to support this determination at the time, and the facility did not conduct a full investigation to rule out mistreatment or inappropriate transfer as potential causes of the fracture. Interviews with facility staff revealed a lack of clarity and communication regarding the reporting requirements and the need for a thorough investigation. The Registered Dietitian and Nursing Home Administrator in Training submitted the Facility Reported Incident the following day, outside the required timeframe. The facility's failure to adhere to its policy and promptly report the injury as an injury of unknown source highlights a deficiency in their reporting and investigation processes.
Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility was found to have several deficiencies related to the cleanliness and maintenance of food service equipment, as well as the proper date marking of potentially hazardous ready-to-eat food products. During a comprehensive tour of the food service area, multiple pieces of equipment, including cutting boards, ovens, and a toaster, were observed to be severely soiled with accumulated and encrusted food residue. Additionally, the walk-in freezer and other refrigeration units were noted to have ice accumulation and soiled surfaces, which could contribute to cross-contamination and bacterial harborage. Further observations revealed that the facility's dishwashing equipment was not functioning properly, with temperature gauges reading below the required levels for effective sanitization. The mechanical dish machine's final rinse temperature gauge was observed at 122 degrees Fahrenheit, significantly lower than the required 180 degrees Fahrenheit. This issue was compounded by missing entries in the dishwasher log, indicating a lack of proper monitoring and maintenance of the equipment. The facility also failed to date mark ready-to-eat food products appropriately. Several items, including a gallon of milk and sandwiches stored in a refrigerator, were found without effective date marks, which is a violation of the FDA Model Food Code. These deficiencies highlight a failure to adhere to established food safety protocols, increasing the risk of foodborne illness among the 82 residents affected by these practices.
Deficiencies in Care Plan Implementation and Infection Control
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six residents, leading to potential unmet medical, physical, mental, and psychosocial needs. For Resident #46, the care plan indicated that smoking supplies should be stored in a locked box on a locked nursing cart, but observations revealed that the resident kept a lighter on his nightstand and stored cigarettes wherever he could hide them. Interviews with staff, including an agency LPN and the Director of Nursing, highlighted a lack of awareness and adherence to the facility's no-smoking policy, which required smoking supplies to be secured by nurses. Resident #29's care plan, which was revised to address fall risks, included an intervention to keep the bed in a low position. However, multiple observations showed that the resident's bed was not consistently kept low, contrary to the care plan. Interviews with a CNA and the Director of Nursing revealed that care plan updates were discussed in meetings, but the information was not effectively communicated or implemented in practice. For Residents #19, #42, #41, and #51, who tested positive for COVID-19, there were no care plans in place for droplet isolation or acute infection management. Despite the presence of STOP signs indicating COVID precautions outside their rooms, the charts lacked documentation of these precautions. The Infection Preventionist confirmed that care plans should be developed for residents with acute infections, but this was not done, indicating a gap in the facility's infection control practices.
Failure to Provide Consistent Hygiene Care
Penalty
Summary
The facility failed to consistently provide showers and bathing to five residents, leading to unmet personal hygiene needs. Resident #27, who had multiple health issues including diabetes and heart failure, was not receiving showers as scheduled due to a COVID outbreak in the facility. Despite the care plan indicating specific shower days, there was confusion among staff about the schedule, and family members reported inconsistencies in the provision of care. Resident #80, who had a history of falls and was at risk due to a previous stroke, was found with long toenails cutting into her skin and was often left soaked in bed. The care plan required regular toileting, but staff failed to assist her to the bathroom, leaving her in a state of neglect. Similarly, Resident #28, a double amputee with end-stage renal disease, reported not receiving showers or hair washing while on isolation precautions, and staff confirmed a lack of resources like shower caps. Resident #5, who was cognitively intact but had multiple health issues, reported infrequent bed baths and inadequate hair washing, leading to visible hygiene issues. Resident #57, also cognitively intact, had not received a shower in two weeks despite not being on isolation, with staff citing short staffing as the reason for missed showers. The facility's failure to provide adequate personal hygiene care was attributed to staffing shortages and mismanagement during a COVID outbreak.
Staffing Shortages Lead to Unmet Resident Care Needs
Penalty
Summary
The facility failed to ensure sufficient staffing, resulting in unmet care needs for residents. Observations and interviews revealed that the facility was consistently short-staffed, particularly on weekends, leading to incomplete tasks such as resident showers and providing fresh water at the bedside. The facility had started using agency staff to cover open shifts, but issues with call-ins and staff not completing their shifts persisted, causing disruptions in the schedule. Management and other staff members had to cover shifts, but this was not enough to meet the residents' needs. Interviews with residents and staff highlighted the impact of the staffing shortages. Residents reported not receiving showers for extended periods, and staff confirmed that when short-staffed, showers and other care tasks were not completed. The facility's staffing requirements indicated a need for more CNAs on each hall than were often available, leading to inadequate care coverage. Staff also reported burnout due to the increased workload and lack of support, with some CNAs quitting or reducing their hours as a result. The facility's administration was aware of the staffing issues, as evidenced by a past noncompliance report. Despite efforts to use agency staff and management covering shifts, the facility continued to struggle with maintaining adequate staffing levels. The lack of proper training and orientation for new staff further exacerbated the situation, leaving them unprepared to meet the residents' needs effectively. The deficiency was evident in the consistent reports of unmet care needs and the facility's inability to provide adequate staffing to ensure resident care.
Failure to Complete Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to ensure that annual competency evaluations were completed for three certified nursing assistants (CNAs) out of five reviewed, which could potentially lead to unmet resident care needs. During a review of employee education files, it was found that no annual competency evaluations were present for the CNAs. Human Resources/Payroll (HR/P) reported that these evaluations were conducted electronically and that the Director of Nursing (DON) was responsible for completing them. Notifications were sent electronically to the DON when evaluations were due, and once completed, CNAs were notified to review them. However, one CNA's evaluation was completed and acknowledged by the manager but not by the CNA, another CNA's evaluation was not completed, and a third CNA's evaluation was completed and acknowledged by the manager but not by the CNA.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure medications were safely stored in two of four medication carts, leading to potential missing medications. On two separate occasions, the C Hall medication cart was observed unlocked and unattended, with no staff present nearby. On the first occasion, an Agency RN, who was on her first day at the facility, returned to lock the cart. On the second occasion, the Director of Nursing (DON) locked the cart, noting that the nurse on duty was also an Agency Nurse on his first day. Additionally, the A Hall medication cart was found unlocked and unattended, further indicating a lapse in adherence to the facility's policy requiring medication carts to be locked when not in direct view of the administering nurse.
Inadequate Infection Control and PPE Use
Penalty
Summary
The facility failed to implement effective infection control measures to prevent the spread of COVID-19 and maintain Enhanced Barrier Precautions (EBP) for several residents. Observations revealed that there were inadequate signs indicating the appropriate personal protective equipment (PPE) to be worn, and PPE carts or bins were not available outside rooms. Staff interviews indicated a lack of consistent understanding and adherence to PPE protocols, with some staff not wearing the required N95 masks and face shields when entering COVID-positive rooms. Specific incidents included a Social Services Coordinator entering a COVID-positive room without a face shield and not sanitizing his glasses after exiting. A Licensed Practical Nurse (LPN) was observed entering a COVID-positive room without donning a face shield and continuing to work without changing her mask. Additionally, a Certified Nursing Assistant (CNA) entered a COVID-positive room without any PPE. These actions contributed to the potential for cross-contamination and the spread of infection within the facility. Resident #23, who had a history of heart failure and other conditions, was diagnosed with COVID-19 and experienced severe respiratory issues, leading to hospitalization and intubation. The resident reported not receiving a requested COVID booster shot. Resident #17, with a tracheostomy and traumatic brain injury, did not have an EBP sign on his door initially, and staff were unaware of the necessary precautions. Resident #51, who tested positive for COVID-19, had no order for COVID precautions in her chart, and staff were not consistently wearing face shields in COVID-positive rooms.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, staff, and the public, affecting 82 residents. Observations revealed that the oxygen storage building was soiled with dead leaves and debris, and the flooring was covered with dust and dirt. During a tour of the common areas, it was noted that the A-B Shower Room had a heavily soiled ventilation grill and a missing atmospheric vacuum breaker in one of the shower stalls. The C-D Shower Room had a leaking hand sink basin and pooling water on the floor. Additionally, the Floor Care Storage Room and Janitor Closet were in disarray and heavily soiled, and the Occupational Therapy/Physical Therapy Storage Room had a non-functional light assembly. Further inspections of resident rooms revealed multiple maintenance issues. In room A107, the hand sink basin was draining slowly, while room A109 had damaged drywall near the soap dispenser. Several rooms, including B102, B105, B109, B110, B113, C103, C106, and D105, had stained and cracked commode base caulking. Room B109 had a non-functional television, which a resident reported had been broken for eight months. Room B110 had a slow-draining sink and a malfunctioning PTAC unit, with the Director of Maintenance confirming that the unit's motherboard was fried and needed replacement. The facility's maintenance inspection and cleaning policies were reviewed, revealing a lack of adherence to these procedures. The TELS work order system showed no entries related to the identified maintenance concerns over the past 90 days. Additional observations included unsmoothed and unpainted spackling on the wall in room A112-1, a bare mattress in room A112-2, and a hole in the wall between the bathroom and closet doors. These deficiencies indicate a failure to provide a safe, functional, sanitary, and comfortable environment as per the facility's policies.
Failure to Promote Resident Dignity and Respect
Penalty
Summary
The facility failed to promote dignity and respect for two residents, resulting in potential feelings of diminished self-worth, sadness, and anxiety. Resident #44, a male with severe cognitive impairment due to a stroke, was observed in a state of undress on multiple occasions. He was seen in his room with his private areas exposed due to an unsecured brief and without a shirt or pants. Additionally, he was observed in the dining room with food debris on his shirt and no staff present to assist him with his meal, further compromising his dignity. Resident #58, a female with dementia and other health issues, was placed on transmission-based precautions due to a COVID-19 diagnosis. Despite her expressed anxiety and fear of dying alone, her request to have her room door open was denied by the staff, citing infection control concerns. The resident's family member reported her anxiety and claustrophobia due to the closed door, but the staff did not accommodate her request, leading to increased anxiety for the resident. The facility's actions and inactions in these cases demonstrate a failure to uphold the residents' rights to dignity and self-determination. The observations and interviews indicate that the facility did not adequately address the residents' needs for privacy, assistance, and emotional support, contributing to their distress and anxiety.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure the safety of self-administration of medication for one resident, resulting in a potential risk for complications. The resident, who was cognitively intact with a BIMS score of 15, had multiple diagnoses including chronic respiratory failure, muscle weakness, and diabetes. During an observation, a registered nurse left a cup of pills at the resident's bedside after administering insulin injections, without confirming the resident's ability to self-administer the medication safely. The resident expressed uncertainty about the medications she was taking and their purposes. Interviews with staff revealed that the facility's policy required an assessment to determine if a resident could safely self-administer medications, which was not completed for this resident. The care plan lacked documentation regarding the resident's ability to self-administer medications, and no lock box was provided for safe storage. The Director of Nursing confirmed that medications should not be left at the bedside unless a resident is assessed as safe to self-administer, and no residents in the facility were currently approved to self-administer their medications.
Facility Fails to Honor Resident Choices by Restricting Vending Machine Access
Penalty
Summary
The facility failed to honor resident choices, impacting two residents who were reviewed for self-determination. Resident #14, who has Type 2 diabetes and is cognitively intact, expressed anger over the inability to access vending machines, which were moved to the employee break room, restricting resident access. This change was made despite Resident #14's dietary order for a cardiac/diabetic diet, which did not explicitly prohibit access to vending machines. Similarly, Resident #42, who is also cognitively intact and has an acquired absence of both legs above the knee, reported frustration over the same issue. The vending machines were relocated due to concerns about residents with special dietary needs not adhering to their diets. However, Resident #42 was on a regular diet and felt unjustly restricted. Interviews with facility staff, including the Maintenance Manager and Clinical Coordinator, revealed a lack of awareness and communication regarding the decision to move the vending machines, which was made by a previous management team.
Failure to Update Care Plans After Changes in Resident Conditions
Penalty
Summary
The facility failed to update or revise the comprehensive care plans for two residents after changes in their conditions, leading to inaccuracies in their care plans. Resident #44, who had severe cognitive impairment and a history of stroke, was observed with a care plan that did not reflect his current dietary orders. His care plan still indicated he was NPO (nothing by mouth) despite a physician's order allowing a regular diet with puree texture and thin consistency. Additionally, his care plan included a focus on the risk for bleeding due to Coumadin intake, even though the medication had been discontinued. Resident #14, who was cognitively intact and had Type 2 diabetes, had a care plan that failed to address her refusal to have her blood sugar checked. Despite receiving insulin injections multiple times a day, there were no documented blood sugar readings after a certain date, and her care plan did not reflect her refusal to have her blood sugar monitored. Interviews with staff revealed that blood sugar checks were not performed unless ordered by a provider or if the resident was symptomatic, and it was noted that Resident #14 frequently refused these checks. The deficiencies in the care plans for both residents resulted in an inaccurate reflection of their current medical needs and conditions. The Director of Nursing acknowledged that care plans should be updated by the Interdisciplinary Team with any changes in the resident's condition, but this was not done for Resident #44's discontinued medication and dietary changes, nor for Resident #14's refusal to have her blood sugar checked.
Failure to Implement and Update Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and update care planned interventions to maintain safety for a resident at risk for falls. The resident, a female with diagnoses including diabetes, stroke with left-sided weakness, and high blood pressure, had a care plan indicating the bed should be in a low position when in bed. Despite this, incident reports revealed multiple falls from bed without injury, and no additional interventions were added to prevent future falls. During an observation, the resident was found in bed with the wheelchair out of reach, and the bed was not in the lowest position. A CNA reported being unaware of the resident's need for posey hipsters and had never seen them, indicating a lack of adherence to the care plan and insufficient supervision to prevent accidents.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that pneumococcal vaccines were offered to a resident, identified as Resident #51, who was reviewed for pneumococcal vaccinations. This oversight resulted in the resident potentially acquiring and experiencing complications related to pneumonia. Resident #51 was admitted to the facility with diagnoses of type 1 diabetes, anxiety, and depression, and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. A review of the resident's immunization records revealed the absence of a pneumonia vaccine, and there were no signed consents or declination of the vaccine documented in the resident's chart. During an interview, the Infection Preventionist confirmed that Resident #51 was due for a pneumonia vaccine and was not offered one upon admission. The facility's Vaccination-Pneumococcal Vaccine Policy, dated October 13, 2023, stated that residents would be evaluated for eligibility to receive the pneumococcal vaccine series upon admission and offered the vaccine unless medically contraindicated or already immunized. The policy also required informed consent to be documented in the resident's medical record, which was not done in this case.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to ensure COVID-19 immunizations were offered to three residents, resulting in an increased likelihood of severe infection and complications related to COVID-19. Resident #51, who was cognitively intact, tested positive for COVID-19 and had not been offered a current COVID-19 vaccine upon admission. Her immunization records showed her last booster was in 2022, and there was no documentation of consent or declination for the current vaccine. Similarly, Resident #343, also cognitively intact, tested positive for COVID-19 and had not been offered the vaccine upon admission. Her last booster was in 2021, and there was no documentation of consent or declination for the current vaccine. Resident #23, with a history of heart failure and other significant health issues, had requested a COVID booster for months but did not receive it. She tested positive for COVID-19 and experienced severe symptoms, including intubation and weakness. Her immunization records showed her last booster was in 2022, and there was no documentation of consent or declination for the current vaccine. The facility's COVID-19 policy required offering the vaccine and documenting education and consent or declination, which was not followed in these cases.
Deficiency in CNA In-Service Training Completion
Penalty
Summary
The facility failed to ensure the completion of 12-hours of annual in-service training for one Certified Nursing Assistant (CNA) out of five reviewed, which could potentially lead to unmet resident care needs. During an interview, the Human Resource/Payroll (HR/P) representative reported that annual in-services are assigned at hire and then annually by the corporate office. However, the HR/P representative was unsure about the tracking of long-term staff training completion and stated that department managers were responsible for this task. The Clinical Coordinator (CC) confirmed that CNA in-services were provided through online modules and in-person training, and department managers should track completion. Despite this, the CC was unable to provide documentation for one of the CNAs, confirming that the CNA had not completed any assigned online education modules and did not meet the required 12-hours of in-service training.
Mail Delivery Delay Causes Resident Frustration
Penalty
Summary
The facility failed to ensure timely delivery of mail to a resident, resulting in feelings of anger and frustration. Resident #42, who is cognitively intact with a BIMS score of 15/15 and has an acquired absence of both legs above the knee, reported not receiving her mail for four days in August 2024. The mail delivery process involved the receptionist sorting the mail and notifying the activities department for distribution. However, during the period in question, the mail was first given to the nursing home administrator for logging before being passed to the activities department. On August 23, 2024, the activities department did not receive any resident mail because the previous administrator did not have time to sort it, resulting in the mail being locked in the administrator's office until the following week. This delay affected Resident #42, who had a package delivered to the facility but did not receive it until the following Monday. The issue was resolved after the previous administrator left, with mail and packages being delivered daily to residents.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by multiple observations of physical deficiencies and unsanitary conditions. During a tour, surveyors noted a broken tile with an unknown white material on the floor, heavily soiled ventilation screens, peeling laminate flooring, and dust-covered window coverings in the dining room. Additionally, the ceiling grid in the dining room had peeling paint hanging over resident dining tables, and the chair railing had deep gouges with jagged wood exposed, posing a risk to residents, especially those in wheelchairs. Other observations included a protruding metal cover with sharp edges, stained floors, and exposed screws in the corridors. Interviews with facility staff, including a CNA, DON, and Maintenance Director, revealed that residents had complained about the cleanliness and condition of the facility. The staff acknowledged the need for environmental improvements, with some staff members donating their time for basic updates. However, the Maintenance Director indicated that additional help was needed to address the building's condition. The facility's policy on providing a homelike environment emphasized the importance of maintaining a clean, sanitary, and orderly environment, which was not being met according to the observations and staff reports.
Resident Denied Access to Personal Funds
Penalty
Summary
The facility failed to ensure that a resident had ready and reasonable access to her personal funds, which resulted in the resident experiencing anxiety and frustration. The resident, who was moderately cognitively impaired and had a history of myocardial infarction, hypertension, and chronic obstructive pulmonary disease, was unable to access $80 from her facility-managed trust account. This money was needed to pay important bills, including insurance on her house and life insurance. The resident had a routine of withdrawing money to give to her son for bill payments, but her request was denied due to the facility's concern about not having enough cash on hand for other residents. Interviews with facility staff revealed that the facility was experiencing difficulties in maintaining an adequate amount of cash for resident withdrawals due to the absence of a full-time Business Office Manager. The Regional Business Office Manager visited the facility once a week to manage the resident trust account, but discouraged withdrawals over $50. The receptionist, who managed day-to-day withdrawals, confirmed the limited cash availability and stated that the resident had not received the full amount requested. The facility's Trust Fund Policy indicated that withdrawals should be made available within three working days, but this was not adhered to in the resident's case.
Misappropriation of Resident's Money Due to Inadequate Safeguards
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's money, resulting in the loss of a lock box containing $152. This incident involved a resident who was admitted to the facility and had a care plan that included the provision of a lock box to keep personal money safe. Despite this measure, the lock box went missing, and the facility's investigation, along with the local police department, was unable to identify a suspect. The resident reported seeing the lock box about two weeks prior to the incident and expressed concerns about the security of her money. The resident experienced feelings of frustration, helplessness, and a lack of trust in the facility's staff following the theft. She reported frequent worry about her money and other belongings, which affected her sleep and led her to refuse to get out of bed to ensure her belongings were safe. Interviews with staff indicated that the resident appeared easily frustrated and that maintaining control over her money was important to her. The Director of Nursing confirmed that the police investigation did not yield a suspect, highlighting the facility's failure to safeguard the resident's property effectively.
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.
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What surveyors actually found near you
We read the 88 citations issued within 25 miles in the last 12 months — including the 2 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 Three Rivers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Orchards At Three Rivers | 4 mi | — | 28 | 1 |
| Fairview Nursing And Rehabilitation Community | 6.4 mi | — | 1 | 0 |
| Froh Community Home | 15.5 mi | — | 0 | 0 |
| Medilodge Of Portage | 18.7 mi | — | 2 | 0 |
| Cass County Medical Care Facility | 20 mi | — | 2 | 0 |
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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.