Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 & Rehabilitation Of Whitehall during CMS and state inspections, most recent first.
The facility did not consistently follow physician orders for medication administration and monitoring. Several residents did not have required pre-administration assessments, such as blood pressure and heart rate, documented before receiving medications like metoprolol and digoxin. In addition, daily weights were not consistently obtained or reported for a resident with CHF, and prescribed doses of prednisone were missed for another resident without proper documentation.
Two residents experienced delays and lack of resolution after voicing grievances about care and communication, including improper catheter care and insufficient notice of medical appointments. Staff did not consistently document or follow up on these concerns, and residents who could not write were not always assisted in filing grievances, resulting in a failure to address issues as required by facility policy.
Two residents experienced unsafe transfers with a new electronic lift due to lack of staff training, unclear care instructions, and failure to follow manufacturer safety guidelines. One resident hit his head on the lift bar, and staff did not check sling placement or properly position the lift during another transfer. Staff were unaware of required safety steps, and no training had been provided on the new equipment.
A resident with a history of recurrent UTIs and an indwelling urinary catheter did not receive proper infection control measures, including consistent use of PPE by staff and correct handling of the catheter drainage bag. Staff placed the catheter bag above bladder level, causing urine backflow, and failed to follow recommended cleaning procedures. The facility's policy lacked guidance on these critical infection prevention steps, and the resident reported lapses in care and hygiene practices.
The facility did not maintain adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, resulting in insufficient oversight and care.
Three residents received medications outside of prescribed parameters or without proper assessment, including one who was given an incorrect insulin dose and required emergency monitoring. Insulin and antihypertensive medications were administered without documented rationale or provider orders when parameters were not met, and relevant orders were missing from nurse binders.
A resident with a fractured shoulder, dementia, and lack of coordination did not receive the required 1:1 meal assistance as outlined in her care plan and Kardex. Observations showed her meal trays were left out of reach or without help, and documentation did not accurately reflect her needs or intake.
A resident with multiple sclerosis and limited mobility developed a pressure ulcer that was not promptly reported to the provider or DPOA, and required treatments were not consistently completed or documented. The resident was observed in the same position for extended periods despite care plan interventions, and there was a lack of timely communication and documentation regarding the wound and its management.
The facility did not consistently follow physician-ordered wound care protocols or provide adequate interventions to prevent skin breakdown for multiple residents with wounds or at risk for pressure injuries. Treatments such as barrier creams, wound cleansers, and dressings were missed on several occasions, and there was no documentation explaining the omissions.
A resident with complex medical needs did not receive care and services according to provider orders and her preferences. The facility failed to provide a gluten-free diet, did not administer wound care as ordered, neglected to obtain daily weights or follow-up labs, and did not notify the provider of significant weight loss. Additionally, there was a discrepancy in the resident's code status documentation, with staff unaware of the correct DNR status.
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 68 residents. Observations included mold and debris in the Walk-In Cooler, undated hot dogs, residue on kitchen equipment, and ice build-up in the Walk-In Freezer. These issues indicate non-compliance with FDA Food Code requirements, increasing the risk of cross-contamination.
The facility failed to implement an effective infection control program, lacking surveillance and documentation of infections among residents and staff. The abrupt departure of the PDON/ICP left the program without oversight, and no records were available for the months of October to December 2024. Employee absences due to illness were not documented or followed up on, indicating non-compliance with infection control policies.
The facility failed to meet the needs of four residents, including a male with Alzheimer's and a female with vascular dementia, by not ensuring call lights were accessible and not responding promptly to requests for assistance. Residents were left without access to necessary items like blankets and fluids, and staff did not adequately address their expressed needs.
A CNA in a LTC facility was found to have verbally abused multiple residents, using derogatory language and profanity. Witnesses confirmed the CNA's inappropriate behavior, which violated the facility's abuse policies. Despite some residents not recalling the incidents, the facility's investigation substantiated the claims, leading to the CNA's termination.
The facility failed to report suspected abuse in a timely manner, involving verbal and mental abuse by staff towards three residents. The facility's policy required immediate reporting to the Administrator, but delays occurred, with the State Survey Agency being informed a day later. A CNA involved in reporting the incident lacked documentation of education or discipline for the delay.
The facility failed to adhere to professional standards in medication administration, resulting in errors for several residents. Controlled medications were not properly documented, and medications were administered without following physician-ordered parameters. Additionally, a resident received an incorrect dose of an antipsychotic medication due to transcription errors.
The facility failed to provide timely and appropriate care to three residents, resulting in untreated conditions and delayed treatments. A resident experienced significant swelling in the feet that was not documented or assessed, another had a missed order to change tube feed guidelines, and a third experienced a delay in treating a urinary tract infection. These deficiencies were attributed to administrative changes, staff turnover, and delays in lab results.
A facility failed to prevent the misappropriation of controlled substances for three residents. A CNA observed an RN pocketing a narcotic pill meant for a resident, who confirmed not receiving it. The incident was not immediately reported to the State Agency, and the RN continued working before being removed. An audit revealed two more missing narcotics belonging to other residents, found in a bathroom. The facility remained non-compliant with narcotic documentation and storage standards.
The facility failed to use wheelchair footrests for two residents, one with paralysis and another with dementia, leading to potential hazards. A CNA propelled a resident without footrests, and another resident, at high fall risk, self-propelled into obstacles, causing entanglement with another wheelchair.
A facility failed to ensure pharmacy recommendations were documented and communicated to the physician for a resident with multiple diagnoses, including diabetes and hypertension. The pharmacist noted irregularities in the medication regimen review, but the report was missing from the resident's medical record, and the physician was not informed. The Nursing Home Administrator confirmed the absence of documentation during the survey.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. One resident received Ciprofloxacin without proper documentation or clinical criteria, while another was given an ineffective antibiotic before switching to an appropriate one. The program lacked proper oversight and documentation, resulting in deficiencies in monitoring and tracking antibiotic use.
The facility failed to provide pneumococcal immunizations per CDC recommendations and resident consent for three residents. A resident with pneumonia and two others with pertinent health conditions had no documentation of receiving or being offered the vaccine. The Infection Control Program, managed by two different PDON/ICPs, did not ensure proper immunization practices, as confirmed by the Regional Director of Clinical.
Surveyors found multiple medication carts left unlocked and unattended, with loose pills present and several opened medications, such as insulin pens and eye drops, lacking required date labels. Staff confirmed that carts should be locked and medications properly labeled, in accordance with facility policy and industry standards.
The facility failed to properly assess, monitor, and document pressure injuries for several residents, leading to inadequate care. One resident had a Stage II pressure injury and a deep tissue injury that were not properly documented or treated, with delays in notifying the physician. Another resident experienced delays in treatment and inconsistent evaluations of a pressure injury, with conflicting documentation. Additionally, a resident with quadriplegia had multiple concurrent treatment orders for a sacral wound, leading to missed treatments. The facility also failed to consistently obtain weights for a resident with CHF, as required.
Failure to Follow Physician Orders for Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that weights were obtained and medications were administered in accordance with physician orders for five residents reviewed for nursing services. For one resident with adrenocortical insufficiency, two doses of prescribed prednisone were not administered as ordered, and there was no documentation of a rationale or provider order for withholding the medication. The DON confirmed the missed doses and lack of documentation. For three residents with congestive heart failure and hypertension, medications such as metoprolol and digoxin were administered without obtaining required pre-administration assessments, including blood pressure and heart rate, as specified in the physician orders. Documentation showed that these assessments were either not performed or not recorded prior to medication administration, and there was no documentation explaining the rationale for administering the medications without the required assessments. Additionally, for one resident with congestive heart failure, daily weights were not consistently obtained as ordered, and significant weight gains that should have triggered provider notification were not acted upon or documented. The DON confirmed that weights were not consistently documented or reported as required by the provider orders.
Failure to Timely Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to resolve grievances in a timely manner for two residents who voiced concerns about their care and communication. One resident, a female with paraplegia, diabetes, and a urinary catheter, reported ongoing issues with staff not using proper personal protective equipment (PPE) during catheter care, improper cleaning of her catheter, and staff refusing to assist her when she experienced pain and issues with her catheter. She stated that she reported these concerns to the Director of Nursing (DON), who documented the issue on a sticky note but did not follow up or provide her with a copy of her grievance. The resident was unable to write due to hand contractures and required staff assistance to document her concerns, which was not consistently provided. Interviews with CNAs confirmed ongoing concerns about infection control and lack of response from the Registered Nurse Unit Manager (RNUM), but no additional grievance forms were found to address these issues. Another resident, a male with a history of stroke and spinal cord disease, expressed frustration with the lack of communication regarding his outside medical appointments. He reported that he was not informed of appointments in advance and was unaware of the facility's grievance process. The resident stated that staff did not offer to help him complete a concern form, despite his difficulty writing. During an interview, the facility's Social Worker acknowledged the concern but did not offer to complete a grievance form, instead stating she would relay the issue to the scheduler. The Appointment Scheduler confirmed attempts to arrange the resident's orthopedic appointment but was unaware of the resident's desire for earlier notification. The Nursing Home Administrator was not aware of the resident's concerns until informed during the survey and noted that staff education on the grievance process was ongoing. The facility's policy required that grievances be documented and responded to promptly, with actions taken to prevent potential violations of residents' rights. However, the investigation found that grievances were not consistently documented, residents were not always assisted in filing grievances when unable to do so themselves, and timely follow-up and resolution were lacking. The absence of proper documentation and response to residents' concerns, particularly regarding infection control and communication about medical appointments, constituted a failure to honor residents' rights to voice grievances without discrimination or reprisal.
Failure to Ensure Safe Transfer Practices with Electronic Lift
Penalty
Summary
The facility failed to ensure safe transfer practices with an electronic lift for two residents who required assistance. One resident expressed discomfort with the new electronic lift, stating it did not fit properly and that he hit his head on the bar during a transfer. The resident's care guide specified the use of a toileting sling and hoyer lift with two staff for transfers, along with cervical precautions, but did not indicate which brand or size of sling should be used. Staff interviews revealed a lack of clarity regarding sling assessments and appropriate equipment selection for the resident, and there was no documentation that the incident of the resident hitting his head had been reported or addressed. During direct observation, staff were seen transferring another resident with the new lift without following manufacturer safety instructions. The bed was in the highest position, and the resident's buttocks did not clear the mattress before being moved. Staff did not check that all sling loops were properly attached before moving the resident, and the lift's legs were not in the fully open position as required for stability. Both staff members involved in the transfer were unaware of the need to check loop placement, ensure the resident cleared the surface before moving, or that the lift legs should be fully open for safety. Further review showed that staff had not received training on the new lift since its purchase, and there was no evidence that management had addressed residents' concerns or reported incidents related to the lift. The instruction manual for the lift provided clear safety requirements that were not followed during observed transfers. The lack of training, unclear care instructions, and failure to follow manufacturer guidelines contributed to unsafe transfer practices and accident hazards for residents requiring lift assistance.
Failure to Implement Proper Infection Control for Catheterized Resident
Penalty
Summary
A deficiency was identified when a resident with a history of recurrent urinary tract infections (UTIs), paraplegia, and an indwelling urinary catheter did not receive proper infection prevention and control measures. The resident's care plan required enhanced barrier precautions, including the use of gowns and gloves during direct care, and specified that the urinary catheter drainage bag should be kept below bladder level to prevent backflow. However, observations revealed that staff did not consistently use personal protective equipment (PPE) such as gloves and gowns when providing care, as reported by the resident herself. The resident expressed concern that this lack of PPE use was contributing to her recurrent UTIs. During direct care, certified nurse aides (CNAs) were observed removing the Foley catheter bag from its privacy bag and placing it on the bed above the resident's bladder level. This action caused urine from the external measuring device to flow back up the catheter tube into the resident's bladder. The CNAs admitted they were unfamiliar with the external measuring device and had not received training on its proper use or the importance of bag placement. Additionally, a soaker pad was found to be wet with urine, and the CNAs stated that the resident did not normally have catheter leakage. A review of the facility's catheter draining bag emptying policy revealed it lacked instructions on keeping the Foley bag below bladder level and on cleaning the emptying device tip with alcohol after use, both of which were included in the hospital's discharge instructions for the resident. The resident also reported that staff did not use alcohol swabs or paper towels when emptying the catheter bag, and that she was not checked or repositioned during the night as required by her care plan.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels were insufficient to address resident care requirements, and there were shifts without a licensed nurse present to oversee care.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to follow professional standards of quality in medication administration for three residents. One resident with diabetes mellitus was given an incorrect dose of insulin after a nurse read the wrong record, resulting in the resident being sent to the emergency room for monitoring due to the risk of hypoglycemia. Another resident with type 2 diabetes mellitus received insulin doses outside of the prescribed blood sugar parameters on multiple occasions, with no documentation of the rationale for administering the medication outside of those parameters or any provider order authorizing such administration. Additionally, this resident was not included on the list of orders with parameters for holding medications in the nurse binder. A third resident with hypertension received Losartan despite blood pressure readings that were outside the parameters set by the provider's order, or without a blood pressure assessment prior to administration. There was no documentation explaining the rationale for administering Losartan outside of the prescribed parameters or any provider order to do so. This resident was also not included on the list of orders with parameters for holding medications in the nurse binder. These findings were based on interviews, record reviews, and review of medication administration records.
Failure to Provide Required Meal Assistance
Penalty
Summary
The facility failed to provide necessary meal assistance to a resident who required 1:1 help with eating due to a fractured right shoulder, dementia, and lack of coordination. On two separate mornings, the resident was observed with her meal tray left out of reach or placed in front of her without assistance, despite care plan and Kardex instructions specifying the need for 1:1 assistance. Documentation inconsistencies were also noted, with staff recording the resident as 'not available' for one meal and indicating partial intake for another, even though the resident reported difficulty eating without help.
Failure to Prevent and Manage Pressure Ulcer and Notify Provider and DPOA
Penalty
Summary
The facility failed to provide care in accordance with professional standards and its own policies to prevent the development and worsening of a pressure injury for a resident with multiple sclerosis and limited mobility. The resident was observed in bed for extended periods, with her position unchanged for several hours, and her heels resting directly on the bed surface despite care plan interventions requiring heel elevation and frequent repositioning. Staff interviews confirmed that the resident was to be repositioned at least every two hours, but observations showed this was not consistently implemented. Documentation review revealed that the resident developed two open sores in the coccyx area, which were not promptly reported to the provider or the resident's DPOA. There was a significant delay in notifying the provider (12 days after initial identification) and the DPOA (18 days after identification) of the pressure injury. Additionally, there was no documentation of new care plan interventions or treatment orders at the time the wounds were first identified, and the DPOA was not informed of subsequent treatment changes in a timely manner. Treatment records showed that ordered wound care was not consistently completed on several dates, and there was a lack of documentation regarding the implementation of new treatments. The facility's own policy required prompt notification of the provider and responsible party, timely implementation of treatments, and regular documentation and monitoring, all of which were not followed in this case. Family interviews further indicated a lack of communication regarding the resident's condition and care, with the DPOA unaware of the wound's status and treatment changes.
Failure to Follow Physician-Ordered Wound Care and Prevent Pressure Injuries
Penalty
Summary
The facility failed to follow physician-ordered wound care and did not provide adequate care to prevent the development of skin breakdown or pressure injuries for six residents reviewed for skin integrity issues. Multiple residents had specific wound care orders, such as the application of zinc oxide, barrier creams, hydrogel, collagen powder, and other treatments at prescribed times and frequencies. However, treatment administration records revealed that these wound care interventions were frequently missed or not completed as ordered. In several cases, there was no documentation in the electronic medical record to account for the missed treatments. Residents affected included individuals with existing wounds or at high risk for skin breakdown, such as those with excoriation, pressure injuries, abrasions, and impaired skin. The missed treatments occurred across various shifts and dates, with some residents not receiving wound care at all during certain scheduled times. The lack of adherence to prescribed wound care regimens and the absence of documentation for missed treatments contributed to the deficiency identified during the survey.
Failure to Follow Provider Orders and Resident Preferences Results in Poor Care
Penalty
Summary
The facility failed to provide care and services in accordance with provider orders, resident preferences, and goals for one resident with multiple complex medical conditions, including congestive heart failure, irritable bowel syndrome, dysphagia, and gluten intolerance. Upon admission, the resident had clear hospital discharge instructions for wound care, a gluten-free diet, daily weights, and follow-up laboratory testing due to a history of hypokalemia and ongoing diuretic therapy. However, the facility did not transcribe or implement these orders accurately. The resident did not receive zinc oxide as ordered for skin excoriation, and the application was not performed three times daily as required. The gluten-free diet was not ordered or provided upon admission, resulting in the resident receiving meals containing gluten, which led to excessive diarrhea and further skin breakdown. Additionally, the facility failed to order or complete the recommended follow-up laboratory tests to monitor electrolyte levels, despite the resident's risk factors and recent history of hypokalemia. Daily weights were not obtained as ordered, and significant weight loss of approximately 23 pounds over six days was not identified or reported to the provider. Documentation in the medical record was incomplete, and there was no evidence that the physician was notified of these significant changes in the resident's condition. There was also a failure to ensure accurate documentation and communication regarding the resident's code status. Although a Do Not Resuscitate (DNR) order was signed and available in the electronic medical record, the active order in the system remained as Full Code, and facility staff were unaware of the discrepancy. These failures resulted in the resident not receiving care and services as ordered and as needed for her medical conditions.
Deficiencies in Kitchen Cleanliness and Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance of food service equipment, as well as to date mark potentially hazardous food items, which could affect 68 residents. During an initial tour of the kitchen, several issues were observed, including mold, mildew, grime, and debris on the shelving and fan compressor grate inside the Walk-In Cooler. Additionally, an undated container of hot dogs was found stored on the shelving. In the cook line area, the can opener blade and holster had food residue and debris, and the commercial blender lid had a yellow/white build-up with black speckles resembling mold or mildew. Further observations revealed ice build-up on the shelving and opened/sealed boxes of food in the Walk-In Freezer, located directly beneath the compressor unit. The Reach-In Cooler units throughout the kitchen were also found to have food residue and debris on the shelving, bottoms, doors, and door openings. These findings indicate a failure to adhere to the 2017 FDA Food Code requirements for equipment cleanliness, food-contact surfaces, and proper food storage, increasing the likelihood of cross-contamination and bacterial harborage.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of surveillance, tracking, and monitoring of infections among residents and staff. During the survey, it was discovered that the facility did not maintain any line lists or documentation of confirmed or suspected infections for the months of October to December 2024. This deficiency was further compounded by the abrupt departure of the Previous Director of Nursing/Infection Control Preventionist (PDON/ICP) S, who had been responsible for the program for the past six weeks. The Regional Director of Clinical (RDC) X confirmed that both PDON/ICP S and the previous PDON/ICP T were responsible for the oversight and maintenance of the Infection Control Program, yet no records were available to demonstrate compliance with the facility's infection control policies. The facility's policy on Infection Prevention and Control-Surveillance, dated July 11, 2018, outlines the requirement for ongoing monitoring and documentation of infections among residents, employees, volunteers, and visitors. However, the review of the 300/400 Unit Scheduling Book revealed employee absences due to illness, with no documentation of the unit they worked in, the residents they interacted with, or any follow-up actions taken to prevent the spread of infection. This lack of documentation and follow-up indicates a failure to adhere to the facility's stated goals of decreasing infection risk and maintaining compliance with state and federal regulations.
Failure to Accommodate Resident Needs
Penalty
Summary
The facility failed to accommodate the needs and preferences of four residents, as observed during a survey. Resident #45, a male with Alzheimer's, lack of coordination, muscle wasting, and a below-the-knee amputation, was repeatedly observed with his call light out of reach, preventing him from requesting assistance. On multiple occasions, he was unable to reach his blanket and expressed feeling cold, yet staff did not adequately address his needs. Similarly, Resident #67, a female with vascular dementia and other conditions, was left shivering in her wheelchair after staff delayed assisting her with dressing, despite her call light being activated. Resident #62, a female with dementia and other health issues, was observed without access to fluids while sitting at the nurses' station and self-propelling in her wheelchair throughout the facility. She expressed thirst, yet no fluids were provided within her reach. Additionally, Resident #7, a male with chronic kidney disease and other serious health conditions, had his call light activated for over an hour without response, leaving him without fresh water. These observations indicate a failure to ensure call lights were accessible and to respond promptly to residents' needs, as outlined in the facility's policy.
Verbal and Mental Abuse by Staff in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal and mental abuse by staff, specifically involving a Certified Nursing Assistant (CNA) identified as CNA B. The incidents involved five residents, with specific allegations of verbal abuse and derogatory language directed at residents. The facility's investigation revealed that CNA B used inappropriate language, including profanity, in the presence of residents, creating an uncomfortable environment. Witnesses, including other CNAs and staff, corroborated these allegations, noting that CNA B often used profanity and derogatory terms in resident care areas. One resident, identified as R12, was reportedly called 'fat and disgusting' by CNA B, although the resident, who was hard of hearing, did not recall the incident. Another resident, R35, was allegedly called an 'a**hole' by CNA B, and although the resident did not remember the specific incident, they confirmed hearing profanity from CNA B. Additionally, R53 was reportedly subjected to derogatory comments about their hygiene, although the resident did not recall these comments. The facility's investigation substantiated these claims based on witness statements, despite some residents not recalling the incidents. The facility's policies on abuse and neglect clearly define verbal and mental abuse, including the use of disparaging language. Despite these policies, the investigation concluded that CNA B's behavior violated these standards, leading to a hostile environment for both residents and staff. The facility's administration was initially unaware of the extent of the issue until it was reported and investigated, resulting in the termination of CNA B's employment due to the substantiated allegations of abuse.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to develop and implement policies and procedures for timely reporting of suspected abuse, neglect, or theft, as required by section 1150B of the Act. This deficiency involved three residents who were subjected to verbal and/or mental abuse by staff members. The facility's Abuse and Neglect Policy and Procedure, dated 3/24/23, outlined that all allegations and suspicions of abuse must be reported immediately to the Administrator or the Administrator's Designee. However, the facility did not adhere to this policy, resulting in a delay in reporting the incidents to the State Survey Agency. The incident involved a Certified Nursing Assistant (CNA) who failed to report allegations of abuse immediately. On 11/11/24, CNA B was reported to have used inappropriate language towards two residents, calling one an "*sshole" and being rude and disrespectful to another. The report was not made to the Interim Nursing Home Administrator until the following day, and the State Survey Agency was not informed until later that day. The personnel file of CNA C, who reported the incident, lacked documentation of any education or discipline regarding the failure to report the allegations timely, although a Teachable Moment form indicated she was educated on the need to report such allegations immediately.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to administer controlled medications following professional standards of practice, resulting in several medication administration errors. For Resident #5, the administration of HYDROcodone-Acetaminophen was not properly documented, with one dose being illegible and not recorded in the Medication Administration Record. Similarly, Resident #46's records showed discrepancies between the Control Substance Record and the Medication Administration Record, indicating that not all doses were administered as documented. Resident #7 also experienced a similar issue, where the Control Substance Record showed fewer doses of oxyCODONE administered than what was documented in the Medication Administration Record. The facility also failed to ensure medications were administered following physician-ordered parameters. Resident #2 was given Midodrine without proper blood pressure assessments, contrary to the physician's orders to hold the medication if blood pressure was over 120. This resulted in the administration of Midodrine when the resident's blood pressure was above the specified threshold. Additionally, Resident #24 received insulin despite having blood sugar levels below the threshold specified in the physician's orders, indicating a failure to adhere to the prescribed parameters for insulin administration. Furthermore, the facility inaccurately transcribed and ordered a newly admitted resident's antipsychotic medication. Resident #68 was prescribed 100 mg of quetiapine at bedtime, but the facility administered 200 mg, resulting in the resident receiving twice the ordered dose. This error persisted from the time of admission, as reflected in the Electronic Medication Administration Records, and was confirmed by the facility's administrator upon review.
Failure to Provide Timely and Appropriate Care
Penalty
Summary
The facility failed to provide quality care to three residents, resulting in untreated conditions and delayed treatments. Resident #14 experienced significant swelling in the feet, which was not documented, monitored, or assessed despite a noticeable weight increase and previous diagnoses of lymphedema and chronic kidney disease. The care plan required daily skin observations and reporting of changes, but the edema was not reassessed or addressed in subsequent physician assessments. Resident #3 had a missed order to change tube feed guidelines, which was recommended by a registered dietitian due to frequent clogging issues. Despite the recommendation to adjust the feeding rate and flush volume, no follow-up or changes were made to the tube feed orders for nearly a month. The oversight was attributed to administrative changes and staff turnover, leading to the recommendation falling through the cracks. Resident #19 experienced a delay in treating a urinary tract infection. The resident reported symptoms consistent with a UTI, but there was a significant delay between the onset of symptoms and the administration of antibiotics. The facility awaited culture results before starting treatment, and the resident was eventually hospitalized due to the UTI and lethargy. The delay was partly attributed to the time taken for lab results to be returned.
Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substances for three residents. An incident occurred where a certified nurse aide observed a registered nurse placing a narcotic pill prescribed to a resident into her pocket. The resident confirmed that he had not received his pain medication. The incident was reported to the interim nursing home administrator, who did not immediately report it to the State Agency or suspend the registered nurse. The registered nurse continued to work an additional shift before being removed from the floor the following morning. An audit of the medication cart used by the registered nurse revealed two additional narcotics were unaccounted for, which belonged to two other residents. These missing narcotics were later found in a medication cup in a bathroom. The facility's policy on abuse and neglect emphasizes providing care in an environment free from misappropriation of property. However, the facility failed to demonstrate substantial compliance with narcotic documentation and storage, remaining out of compliance with professional standards for controlled drug administration and documentation.
Failure to Use Wheelchair Footrests Leads to Hazards
Penalty
Summary
The facility failed to ensure the use of footrests on wheelchairs for two residents, leading to potential accident hazards. Resident #44, a female with left-sided paralysis following a stroke and abnormal posture, was observed being propelled by a Certified Nurse Aide (CNA) down a hallway without footrests on her wheelchair. This lack of footrests could contribute to instability and potential injury during transport. Resident #62, a female with dementia, rheumatoid arthritis, and a high risk for falls, was also observed without footrests on her wheelchair. She was pushed by a CNA and later self-propelled down a hallway, encountering obstacles such as meal service carts. This led to a situation where she leaned forward to move a cart, and subsequently, her wheelchair became entangled with another resident's wheelchair, causing frustration and requiring staff intervention to resolve the situation.
Failure to Document and Communicate Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were received and reviewed by the physician for a resident, leading to a deficiency in the medication regimen review process. The facility's Medication Regimen Review (MRR) Policy and Procedure requires that any irregularities identified by the pharmacist be reported to the attending physician, medical director, and Director of Nursing Services within seven working days. However, for one resident, the pharmacist noted irregularities on the Medication Regimen Review form but did not specify what they were, and the corresponding report was not found in the resident's electronic medical record. The resident in question had multiple diagnoses, including diabetes, hypertension, hyperlipidemia, and paranoid schizophrenia. Despite the pharmacist's indication of irregularities, there was no documentation in the resident's medical record to show that the physician was aware of these recommendations. During interviews, the Nursing Home Administrator acknowledged the absence of the pharmacy report and the lack of evidence that the physician had been informed. The facility was unable to provide any further documentation related to the pharmacy recommendation by the completion of the survey.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, resulting in inappropriate antibiotic utilization for two residents. The previous Director of Nursing/Infection Control Preventionist (PDON/ICP) abruptly ended her employment, leaving the program without proper oversight. The Regional Director of Clinical (RDC) confirmed that the PDON/ICP was responsible for monitoring antibiotic use and ensuring clinical criteria were met, but this was not effectively carried out. For Resident #5, there was no documentation of clinical criteria for the use of Ciprofloxacin, no culture and sensitivity report reviewed, and no provider rationale for the continued use of the antibiotic. This lack of documentation and oversight led to the inappropriate administration of antibiotics without proper justification or evidence of necessity. Resident #45 was initially prescribed Macrobid for a UTI, but a culture and sensitivity report later indicated resistance to this antibiotic. Despite this, Macrobid was administered twice before switching to Ciprofloxacin, which was deemed appropriate by the culture report. The facility's Infection Control Program documentation lacked surveillance and tracking of infections and antibiotic use, further highlighting the deficiency in the antibiotic stewardship program.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to provide pneumococcal immunizations according to CDC recommendations and resident consent for three residents. Resident #18, a female with a history of pneumonia, had no documentation of receiving or being offered the pneumonia vaccine since her admission. Similarly, Resident #4, who was readmitted with pneumonia, lacked documentation of vaccine administration or discussion with her guardian. Resident #56, with lung and heart disease, also had no record of receiving the vaccine or having it discussed with him or his guardian. These deficiencies were identified during a review of the residents' electronic medical records. The facility's Infection Control Program, which was overseen by two different Directors of Nursing/Infection Control Preventionists (PDON/ICP) over a short period, failed to ensure that the necessary immunizations were offered and documented. The Regional Director of Clinical confirmed the absence of historical data for the pneumococcal immunizations for these residents and acknowledged the need to obtain consent and offer the immunizations. The facility's policy on Infection Prevention and Control, dated 2018, emphasized the importance of offering immunizations to decrease the incidence of preventable infectious diseases, but this was not adhered to in these cases.
Unsecured Medication Carts and Improper Medication Labeling
Penalty
Summary
Surveyors observed multiple instances where medication carts were left unlocked and unattended by licensed nursing staff. Specifically, one medication cart was found unlocked and unattended, containing five loose pills in a drawer, and several medications, including Lantus insulin pens and brimonidone eye drops, were not labeled with the date they were opened. Another medication cart was found with eight loose pills in a drawer. Additionally, both medication carts on a particular hall were observed sitting side by side, unlocked and unattended, while a registered nurse was away from the carts. Interviews with staff confirmed that medication carts should be locked at all times when not attended by a nurse, and that loose pills should not be present in the carts. Review of facility policy and industry standards indicated that all drugs and biologicals must be stored in locked compartments and that opened medications should be dated according to manufacturer guidelines. The failure to secure medication carts and properly label opened medications was directly observed and acknowledged by staff.
Deficiencies in Pressure Injury and Wound Care Management
Penalty
Summary
The facility failed to adequately assess, monitor, and document pressure injuries and wounds for several residents, leading to deficiencies in care. For one resident, there was a lack of proper assessment and documentation of pressure injuries, including a Stage II pressure injury to the buttocks and a deep tissue injury to the left foot. The resident was observed multiple times without necessary protective equipment, such as offloading boots and cushions, and there was a delay in notifying the physician and obtaining treatment orders for new injuries. Additionally, the resident's care plan was not updated with meaningful interventions following the identification of pressure injuries. Another resident experienced a delay in the treatment of a pressure injury, with inconsistent evaluations and contradictory documentation regarding the condition of the injury. The facility staff failed to implement hospice-provided wound care orders, and there was a lack of documentation regarding the notification of the physician and guardian about the pressure injury. The resident's care plan was not updated promptly, and there were discrepancies in the assessment of the pressure injury, with conflicting reports about its severity and condition. The facility also failed to ensure that another resident received appropriate wound care as per physician orders. There were multiple concurrent treatment orders for the resident's sacral wound, leading to confusion and missed treatments. The facility did not document any attempts to clarify these orders, resulting in inadequate wound care. Additionally, the facility did not consistently obtain and document weights for a resident with congestive heart failure, as required by the treatment plan. The Director of Nursing acknowledged the lack of oversight and monitoring of pressure injuries and wounds, indicating systemic issues in the facility's wound management program.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Whitehall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Nursing And Rehabilitation Community | 9.8 mi | — | 12 | 0 |
| Harbor Terrace Senior Living | 12.3 mi | — | 10 | 0 |
| Optalis Health & Rehabilitation Of Muskegon | 13.3 mi | — | 39 | 0 |
| Lake Woods Nursing & Rehabilitation Center | 13.6 mi | — | 2 | 0 |
| Roosevelt Park Nursing And Rehabilitation Communit | 14 mi | — | 3 | 0 |
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