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 South Haven Nursing And Rehabilitation Community during CMS and state inspections, most recent first.
A resident with mental health diagnoses was prescribed PRN hydroxyzine for anxiety without a 14-day stop date, and no provider rationale was documented to justify use beyond this period. The DON confirmed that the required stop dates were not in place for the medication orders.
A resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unnoticed, despite being identified as an elopement risk. Staff were aware of the resident's patterns, such as checking doors and expressing a desire to leave, but there was no individualized documentation or consistent monitoring of these behaviors prior to the incident. The resident was found walking along a busy road by a staff member and returned to the facility.
Two residents with severe cognitive impairment and a history of exit-seeking behaviors were not provided with individualized care plans. Instead, generic interventions were used, and specific behaviors such as fixation on cars and cigarettes were not addressed. One resident was able to leave the facility unsupervised, and staff interviews revealed a lack of documentation and monitoring for escalating behaviors, with care plans relying on non-individualized templates.
The facility lacks a full-time Registered Dietitian or Certified Dietary Manager to oversee nutritional services. The Dietary Supervisor, in the role for two years, is not yet certified but is taking classes. A dietitian visits only a couple of times a week, increasing the risk of food service sanitation failures and inadequate assessment of high-risk residents.
A long-term care facility was found to have multiple deficiencies in food safety and sanitation during a survey. The kitchen had issues with unlabeled and undated food items, dirty equipment, and improper storage practices. The walk-in cooler and dry storage areas contained items without proper labeling, and the kitchen equipment was not maintained in a clean condition. Additionally, the refrigeration unit in the resident area was at an unsafe temperature, posing a risk of foodborne illness.
The facility failed to maintain an effective water management plan and infection control program. The Maintenance Director was unsure of control measures beyond routine flushing and had not conducted water testing. The Infection Preventionist missed resident vaccinations, lacked a tracking process, and failed to ensure staff training on infection control. The infection control log was incomplete, and there was no clear responsibility for infection monitoring, indicating deficiencies in both programs.
A facility failed to implement an antibiotic stewardship program and monitor antibiotic use for a resident. The Infection Preventionist (IP) did not assess antibiotic use according to Mcgeer's criteria and lacked documentation on antibiotic indications, dosages, or durations. The IP also did not follow up on outcomes or provide feedback on antibiotic use, relying on nursing staff documentation. The Director of Nursing (DON) did not oversee the stewardship program, leaving all responsibilities to the IP, resulting in potential inappropriate antibiotic use and resistance.
The facility failed to maintain cleanliness and repair, affecting resident rooms and common areas. Observations revealed dust and debris in rooms, stained ceiling tiles, and disrepair in utility spaces. Residents with chronic obstructive pulmonary disease were exposed to dusty fans, and one resident had to clean her own bathroom due to dissatisfaction with housekeeping. Damaged and dirty wheelchairs were also noted, with inconsistencies in cleaning schedules and maintenance awareness.
A resident with cognitive impairment and physical limitations was repeatedly found with the call light out of reach, preventing them from calling for assistance. Despite the care plan's directive to keep the call light accessible, observations showed it was often on the floor or under the bed.
A facility failed to create a comprehensive care plan for a resident on Eliquis, an anticoagulant prescribed for deep vein thrombosis. Despite the resident's diagnoses of congestive heart failure and hypertension, no care plan was in place to address the potential side effects of the medication. The MDS Coordinator and DON both acknowledged the oversight, emphasizing the importance of care plans for high-risk medications.
A facility failed to implement care plan interventions for a resident with muscle contracture, as the resident was observed not wearing prescribed splints on multiple occasions. Despite occupational therapy recommendations and care plan documentation, staff interviews revealed a lack of awareness and adherence to the care plan, leading to the potential for worsening contractures.
A resident with dementia and a history of falls experienced a fall resulting in facial injuries due to inadequate supervision and failure to implement safety interventions. The resident, who self-ambulated in a wheelchair, fell near a chapel ramp without caution signs, despite this being part of her care plan. Observations showed the resident was often left unattended, and staff admitted to not applying necessary safety measures.
A facility failed to attempt a required Gradual Dose Reduction (GDR) for a resident's antidepressant and antipsychotic medications, potentially leading to unnecessary dosing. The resident, with a diagnosis of unspecified mood affective disorder, was prescribed Olanzapine and Sertaline. Despite the care plan indicating a need for dose reduction, there was no documentation of GDR attempts or justification for not attempting one. Interviews revealed a lack of awareness and documentation regarding GDR attempts, with reliance on a local mental health provider without evidence of collaboration or follow-up visits.
A resident with diabetes received an incorrect dose of insulin due to a new nurse's error, leading to a significant drop in blood sugar levels. The nurse, who was still in orientation, administered 32 units of short-acting insulin instead of the prescribed doses, causing the resident to experience severe symptoms and miss a dialysis appointment. The error was reported and investigated by the facility's staff.
A facility failed to administer a pneumococcal vaccine to a resident with chronic obstructive pulmonary disease, despite consent from the guardian and the resident being due for the vaccine. The Infection Preventionist acknowledged the oversight, citing staff turnover and a backlog in the vaccine program as contributing factors.
A facility failed to offer a COVID-19 vaccination to a resident with chronic obstructive pulmonary disease, as there was no record of vaccination in their Electronic Health Record. The Infection Preventionist admitted to not screening or offering the vaccine to the resident and lacked a systematic approach to ensure staff were educated and offered the vaccine, relying only on posted signs during clinics.
The facility failed to ensure timely care and services for three residents, resulting in long call light wait times, cluttered rooms, and potential feelings of diminished self-worth. One resident reported waiting up to two hours for assistance, while another's family member noted frequent delays and clutter. A third resident in extreme pain also experienced delays in receiving care.
A resident with cognitive impairments reported being punched by a CNA after using racial slurs. The facility's investigation revealed inconsistencies in staff and resident accounts, and the incident was not adequately documented. The deficiency highlights a lapse in protecting the resident from potential abuse and the need for improved adherence to abuse prevention policies.
The facility failed to ensure physician orders for scheduled pain medications were in place and did not accurately document the administration of controlled medications for a resident with terminal cancer. This resulted in inadequate pain management and potential drug diversion.
The facility failed to maintain safe infection control practices for a resident on Enhanced Barrier Precautions due to chronic wounds and a Foley catheter. Staff were observed handling the resident's catheter bag and transferring the resident without wearing the required PPE, and there was a lack of hand hygiene and PPE availability, leading to potential cross-contamination.
Failure to Limit PRN Psychotropic Medication to 14 Days Without Provider Rationale
Penalty
Summary
The facility failed to ensure that as needed (PRN) psychotropic medications for a resident included a stop date not exceeding 14 days, as required. A male resident with diagnoses of schizoaffective disorder, bipolar disorder, and anxiety disorder was prescribed hydroxyzine, an antihistamine also used for anxiety, on a PRN basis. The medication orders were written with start and discontinue dates that exceeded the 14-day limit for PRN psychotropic medications, and there was no documentation of a provider rationale to justify extending the use beyond this period. During an interview, the Director of Nursing (DON) confirmed that PRN psychotropic medications should be limited to 14 days unless a provider documents a rationale for extension. Review of the resident's orders showed that the required 14-day stop dates were not implemented for both instances of the hydroxyzine prescription, and no provider rationale for the extended use was provided by the time of the survey exit.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safety and prevent the elopement of a resident who was assessed as being at risk for elopement. The resident, who had diagnoses including unspecified dementia, unspecified mood disorder, unsteadiness on feet, and required assistance with personal care, was severely cognitively impaired as indicated by a BIMS score of 3/15. Despite being identified as an elopement risk and having a care plan that included interventions such as alarms and monitoring, the resident was able to leave the facility premises unnoticed by staff. The resident was last seen by staff approximately 15 minutes before being found outside the facility, walking along a road without a sidewalk, by a staff member who happened to be driving by. Multiple staff interviews revealed that the resident had a known pattern of exit-seeking behaviors, including frequently checking doors, setting off alarms, and expressing a desire to leave the facility for cigarettes or to see white cars. Staff also reported that the resident's behaviors would escalate, but there was no documentation or consistent monitoring of these behaviors in the resident's medical record prior to the elopement event. Although the facility had a blanket behavior monitoring order for all residents, it was not individualized or specific to the resident's known behaviors. Communication about the resident's increased exit-seeking behaviors was primarily verbal and not consistently documented or shared with all staff. There was no evidence of behavior logs or specific interventions being implemented or documented in response to the resident's escalating behaviors prior to the incident, which contributed to the failure to prevent the elopement.
Failure to Individualize Care Plans for Residents at Risk of Elopement
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents with severe cognitive impairment and a history of exit-seeking behaviors. For one male resident with dementia and a BIMS score indicating severe cognitive impairment, the care plan included generic interventions such as door alarms, quarterly elopement assessments, and offering distractions. However, the care plan did not address the resident's specific behaviors, such as his fixation on white cars and cigarettes, or his pattern of looking out windows and attempting to exit the building. Multiple staff interviews confirmed that the resident routinely checked doors, set off alarms, and expressed a desire to leave the facility for cigarettes or to return home, but these behaviors were not specifically documented or communicated in his care plan. On one occasion, this resident was able to leave the facility unsupervised and was found walking alone along a road by a staff member, who then returned him to the facility. Staff interviews revealed that while staff were aware of the resident's exit-seeking tendencies and specific interests, such as white cars and cigarettes, this information was not consistently documented or included in the care plan. The Director of Nursing and other staff acknowledged that care plans were not individualized and that there was no system in place to monitor or document escalating behaviors that could lead to elopement. A second female resident with dementia and severe cognitive impairment was also identified as an elopement risk, with a history of looking for family and attempting to leave the facility. Her care plan similarly relied on template interventions and did not include specific, individualized strategies to address her behaviors. Staff interviews indicated a lack of awareness and monitoring for elopement risk, and the care plan was not customized to reflect the resident's unique needs or patterns of behavior. The facility's practice of using pre-selected, non-individualized care plan templates contributed to the failure to adequately address and manage the elopement risks for both residents.
Lack of Full-Time Dietitian or Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time Registered Dietitian or a Certified Dietary Manager to oversee kitchen and clinical nutritional services. During a kitchen tour, the Dietary Supervisor (DS) revealed that the facility only has a dietitian who visits a couple of times a week. The DS, who has been in the role for about two years, is not yet a Certified Dietary Manager but is currently taking classes to become one. She mentioned that it has been challenging to fit the classes into her schedule, and she is seeking an extension to complete them. This deficiency increases the potential for food service sanitation failures, foodborne illness, or inadequate assessment of high-risk residents among all residents.
Food Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as observed during a kitchen tour. The kitchen was found to have multiple areas of concern, including a dishwasher area with spilled powdered detergent and discoloration from dripping water. The dish area had a leaking three-compartment sink with a container to catch leaks, and a bucket of liquid detergent covered with dirt and debris. The kitchen prep area had clean utensil drawers with crumbs and debris, cracked spatulas, and equipment with excess buildup and dried food debris. The walk-in cooler contained several items without labeling or dating, such as raw onion, butter, creamed corn, and various other food items. The dry storage area also had unlabeled and undated items, including dry cereal, quick oats, and various mixes. The facility's failure to properly label and date food items, as well as maintain cleanliness and organization in storage areas, poses a risk of foodborne illness among residents. Additionally, the facility's equipment and surfaces were not maintained in a clean and sanitary condition. The can opener, microwave, and ice machine area had significant dirt and debris accumulation. The dish machine area had a cross-connection that could contaminate the potable water supply, and the refrigeration unit in the Bunny Patch resident area was found to be at an unsafe temperature. These deficiencies indicate a lack of adherence to the 2017 FDA Food Code, which outlines necessary standards for food safety and equipment maintenance.
Deficiencies in Water Management and Infection Control Programs
Penalty
Summary
The facility failed to maintain an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). During an interview, the Maintenance Director was unable to specify control measures beyond routine flushing of domestic fixtures and admitted to not conducting water testing due to waiting on a tester. Additionally, the water line in the family room was not being flushed. The Water Management Plan had not been reviewed with the administrator, and the facility's Water Pathogen Risk Reduction document lacked a date, indicating a lack of comprehensive implementation and documentation. The facility's infection control program was found to be ineffective, as the Infection Preventionist (IP) reported missing resident vaccinations and lacking a thorough tracking process. The IP was unable to confirm staff training on cleaning and disinfecting reusable medical equipment and environmental cleaning. The IP also failed to provide examples of infection control education for staff and could not explain how infection control audits were conducted or tracked. The facility's infection control policies and procedures were not regularly reviewed or updated, and there was no clear process for tracking employee illness or early detection of potential infectious residents. The IP's infection control log for September 2024 was incomplete, only tracking residents prescribed antibiotics, and lacked detailed information on symptoms, diagnosis, and monitoring. The IP relied on nursing staff for infection monitoring and did not ensure all staff received necessary education. The Director of Nursing (DON) reported that the IP was responsible for the infection control program, but the IP was still being assisted by the DON, indicating a lack of clear responsibility and oversight in the infection control program.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operationalize an antibiotic stewardship program, as well as to monitor the appropriate use of antibiotics for a resident. The deficiency was identified during a review of the records and an interview with the Infection Preventionist (IP) C, who was responsible for ensuring that Mcgeer's criteria were used when prescribing antibiotics. However, IP C admitted to missing the assessment of antibiotic use for a resident who had been on antibiotics in September 2024. Furthermore, IP C was unable to provide a list of residents on antibiotics or documentation regarding the indication, dosage, or duration of antibiotic use. Additionally, IP C did not follow up on the outcomes of residents prescribed antibiotics, relying instead on nursing staff documentation. There was no established process for providing feedback on antibiotic use, resistance patterns, or prescribing practices. IP C, being new to the position, was still receiving assistance from the Director of Nursing (DON) B, who reported not overseeing or monitoring the facility's antibiotic stewardship, leaving all responsibilities to IP C. This lack of oversight and documentation resulted in the potential for inappropriate antibiotic utilization and resistance.
Facility Fails to Maintain Cleanliness and Repair
Penalty
Summary
The facility failed to maintain cleanliness and repair in several areas, affecting both resident rooms and common utility spaces. Observations revealed dust and debris accumulation in resident rooms, with specific issues such as stained ceiling tiles indicating possible roof leaks. Shared bathrooms were found with dirt accumulations, and utility rooms had cabinets in disrepair, making them difficult to clean. Additionally, a janitor's closet had a leaking hot water valve and an unlabeled spray bottle, while the central supply room was missing a light shield. Residents were directly impacted by these deficiencies. For instance, two residents with chronic obstructive pulmonary disease were exposed to dusty fans blowing directly towards them, which were not cleaned regularly as per the facility's protocol. Another resident expressed concerns about the cleanliness of her shared bathroom, which was often found with feces on the floor and toilet, despite being cleaned by housekeeping. The resident resorted to cleaning the bathroom herself due to dissatisfaction with the facility's cleaning efforts. Further issues included damaged and dirty wheelchairs, with exposed foam on arm covers and dirt on the wheels and frames. Housekeeping and maintenance staff interviews revealed inconsistencies in cleaning schedules and a lack of awareness about certain deficiencies, such as missing window screens and cracked walls. These observations highlight a systemic issue in maintaining a clean and safe environment for residents, staff, and visitors.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident, resulting in the inability to call for staff assistance. The resident, who was moderately cognitively impaired with a history of cerebrovascular accident and left-sided weakness, was observed multiple times with the call light out of reach. On one occasion, the call light was on the floor, and on another, it was under the bed, both times making it inaccessible to the resident. The resident reported using the call light to request help but sometimes could not find it. A Certified Nursing Assistant confirmed that the resident used the call light to ask for assistance. Despite the care plan specifying that the call light should be within reach, observations over several days showed that this was not consistently ensured, leading to potential unmet care needs.
Failure to Implement Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was prescribed an anticoagulant medication, Eliquis, for a history of deep vein thrombosis. The resident, a female with diagnoses of congestive heart failure and hypertension, did not have a care plan that addressed her anticoagulant therapy, which is crucial due to the potential side effects such as heavy bruising. The MDS Coordinator, responsible for creating care plans for high-risk medications, acknowledged the absence of a care plan for the resident's anticoagulant therapy during an interview and record review. The Director of Nursing also confirmed that care plans should be in place for high-risk medications to ensure staff are aware of and monitor potential side effects.
Failure to Implement Care Plan for Contracture Prevention
Penalty
Summary
The facility failed to implement care plan interventions to prevent the worsening of contractures for a resident with a diagnosis of muscle contracture. The resident was admitted with pertinent diagnoses, including contracture of muscles, and had been discharged from occupational therapy with specific recommendations for wearing a right hand T bar splint and a left upper extremity hand roll or gauze during the day as tolerated. These recommendations were documented in the resident's care plan, which specified the use of these assistive devices during morning care and their removal at lunch or as tolerated. Observations on multiple occasions revealed that the resident was not wearing the prescribed splints on the right hand, left hand, or elbow while sitting in a wheelchair in the dining room or lying in bed. Interviews with facility staff, including a Physical Therapy Assistant and a Certified Nursing Assistant, confirmed that the expectation was for the CNAs to place the splints on the resident during morning care. However, the CNA reported being unaware of the requirement for the resident to wear the splints during the day, indicating a lapse in communication or adherence to the care plan, leading to the potential for worsening of the resident's contractures.
Failure to Implement Safety Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and implement necessary safety interventions for a resident, identified as R15, who was at high risk for falls due to cognitive impairment and a history of falls. R15, who had dementia and was able to self-ambulate in a wheelchair, experienced a fall resulting in facial bruising and a laceration that required sutures. The fall occurred when R15 was self-ambulating near the chapel, an area with a ramp that posed a hazard, and there were no yellow caution signs or strips in place to warn of the descent, despite this being an intervention listed in the resident's care plan. The resident's care plan, which identified her as at risk for falls due to dementia, altered mental status, and limited mobility, included interventions such as keeping her in high traffic areas and applying yellow caution strips at the start of the ramp to the chapel. However, these interventions were not consistently implemented. Observations revealed that R15 was often left unattended in her wheelchair, both in the dining room and near the nursing station, where she attempted to self-ambulate, leading to her legs becoming tangled in the wheelchair's foot pedals. Interviews with staff and family members highlighted concerns about the lack of supervision and the failure to implement safety measures. Family members questioned why R15 was left unsupervised, and staff acknowledged that the resident was known to self-ambulate throughout the facility. The Director of Nursing admitted that the yellow caution strips were never applied, despite being part of the care plan, and the resident continued to be at risk for falls due to inadequate supervision and environmental hazards.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a required Gradual Dose Reduction (GDR) of antidepressant and antipsychotic medications for a resident, resulting in the potential that the resident was receiving the medication at an unnecessary dose or for an unnecessary length of time. The resident was admitted with diagnoses including unspecified mood affective disorder and was prescribed Olanzapine and Sertaline. The care plan indicated a need for dose reduction, but there was no documentation of any attempts for GDRs or justification for not attempting a GDR since October 2023. Interviews with the Director of Nursing (DON) and the Social Worker (SW) revealed a lack of awareness and documentation regarding the resident's GDR attempts. The DON could not report the last GDR attempt or any clinical indication for not attempting a GDR. The SW indicated reliance on a local mental health provider for managing the resident's psychotropic medications, but there was no evidence of collaboration or follow-up visits for nearly a year. The facility was unable to provide documentation justifying the absence of GDR attempts prior to the survey exit.
Medication Error in Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. A resident, who was cognitively intact and had a diagnosis of diabetes, reported receiving an incorrect dose of insulin. The error occurred when a new nurse, who was still in her orientation period, administered 32 units of short-acting insulin instead of the prescribed 2 units of short-acting and 30 units of long-acting insulin. This mistake was attributed to the nurse being nervous and in a rush, leading her to not verify the correct type of insulin before administration. As a result of the medication error, the resident experienced a significant drop in blood sugar levels, leading to symptoms such as fatigue, inability to keep her eyes open, and verbal non-responsiveness. The resident's blood sugar dropped to 54, prompting immediate intervention with carbohydrates and milk to stabilize her condition. The error also caused the resident to miss a dialysis appointment. The incident was reported by the physical therapist and investigated by the Director of Nursing, who confirmed the error and provided education to the nurse involved.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that residents were properly screened for eligibility to receive pneumococcal vaccinations, specifically for one resident among those reviewed. Resident #22, who was admitted with chronic obstructive pulmonary disease, had a consent form signed by their guardian indicating a willingness to receive the pneumococcal vaccine, provided it had been more than three years since the last dose. The Michigan Care Improvement Registry showed that Resident #22 was due for a pneumococcal vaccine on 9/7/22, but this was not administered. During an interview, the Infection Preventionist (IP C) confirmed responsibility for screening and administering vaccines and acknowledged that Resident #22 was due for an updated pneumococcal vaccine. However, IP C could not explain why the vaccine had not been administered, attributing the oversight to the facility's vaccine program being behind schedule due to staff turnover and her recent assumption of the IP position in March 2024. This lapse resulted in the potential risk of acquiring or transmitting pneumococcal pneumonia.
Failure to Offer COVID-19 Vaccination to Resident
Penalty
Summary
The facility failed to ensure that COVID-19 immunizations were offered to a resident, leading to a deficiency in their vaccination protocol. Resident #51, who was admitted with chronic obstructive pulmonary disease, did not have any record of receiving a COVID-19 vaccination in their Electronic Health Record. Although a Vaccine Consent Form indicated that the resident had previously received a COVID-19 vaccination, it did not specify if additional doses were desired. During an interview, the Infection Preventionist (IP) admitted to not having offered the COVID-19 vaccine to Resident #51 and acknowledged a lapse in tracking and offering vaccinations to both residents and staff. The IP also reported that there was no systematic approach to ensure staff were screened, educated, and offered the vaccine annually, relying instead on posting signs during clinics without further follow-up.
Failure to Ensure Timely Care and Services
Penalty
Summary
The facility failed to ensure timely care and services to promote dignity for three residents, resulting in long call light wait times, cluttered rooms, and potential feelings of diminished self-worth, sadness, and frustration. Resident #200, who was cognitively intact, reported waiting up to two hours for assistance with repositioning and an hour for help with changing and getting ready for bed. The Director of Nursing and Unit Manager were unaware of any staffing issues that could explain the delays, and the facility lacked a specific policy or timeframe for responding to call lights. Resident #201's family member reported that the resident often had to wait up to an hour for call lights to be answered and was frequently found lying in bed with food on him and in a soiled brief. The room was observed to be cluttered with various items. Resident #202, who was in extreme pain from terminal cancer, also experienced delays in receiving pain medication and toileting assistance, with staff appearing bothered when asked for help. Observations of the nurses' station revealed outdated and incomplete information on a dry erase board, further indicating a lack of attention to detail and resident care needs.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff. Resident #201, who was moderately cognitively impaired and had a history of stroke, weakness, depression, anxiety, and dementia, reported being punched by a CNA. The incident was initially reported by a hospice worker who observed a bruise on the resident's right upper arm. The facility's Director of Nursing (DON) confirmed the presence of the bruise but did not document it with measurements or photographs. The resident admitted to using racial slurs towards the CNA, which led to the alleged physical altercation. Multiple staff members, including the CNA involved, reported that the resident had been combative during care, but other staff and family members noted that the resident was typically pleasant and non-combative. The facility's investigation included interviews with the resident, staff, and family members, but there were inconsistencies in the accounts of the resident's behavior and the events leading to the bruise. The facility's abuse prevention policy explicitly states that striking a combative resident is not an appropriate response, yet the investigation did not conclusively determine whether the CNA's actions constituted abuse. The care plan for the resident was updated after the incident to address his behavioral symptoms, including negative racial statements and combativeness during care. However, the facility's failure to adequately document and investigate the incident, as well as the conflicting reports from staff and the resident, indicate a deficiency in protecting the resident from potential abuse. The facility's policy on abuse prevention emphasizes the importance of professional behavior and the safety and well-being of residents, but the handling of this incident suggests a lapse in adherence to these standards. The deficiency highlights the need for more thorough documentation and consistent application of abuse prevention protocols to ensure resident safety. The facility's response to the incident, including the lack of immediate documentation and the delayed care plan update, underscores the importance of timely and accurate reporting in abuse investigations. The conflicting accounts from staff and the resident further complicate the investigation, making it difficult to determine the exact nature of the incident and whether the resident's rights were adequately protected. The facility's failure to protect the resident from potential abuse and the inconsistencies in the investigation process indicate a need for improved training and adherence to abuse prevention policies. The incident underscores the importance of maintaining a safe and respectful environment for all residents, particularly those with cognitive impairments and behavioral challenges. The facility must take steps to ensure that all staff are trained in appropriate responses to combative behavior and that incidents of potential abuse are thoroughly documented and investigated. The deficiency in this case highlights the need for ongoing monitoring and quality improvement efforts to protect residents from harm and uphold their rights to a safe and dignified living environment.
Failure to Implement Physician Orders and Document Controlled Medications
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice by not ensuring physician orders were in place for scheduled pain medications and not accurately documenting the administration of controlled medications for a resident with terminal cancer. The resident, who was in extreme pain, had a physician's order to change his narcotic pain medication from PRN (as needed) to a scheduled dose. However, this change was not implemented until days later, resulting in the resident receiving inadequate pain management during his stay at the facility. The resident's family member reported that the call light for pain medication often went unanswered, and the resident was eventually transferred to a hospital where he passed away shortly after. The Director of Nursing (DON) confirmed that new orders should go into effect immediately and acknowledged past issues with the physician responsible for the resident's care. Additionally, the controlled substance sign-out sheets revealed that the resident received multiple doses of pain medication that were not recorded in the Medication Administration Record (MAR), indicating a failure in proper documentation and potential drug diversion. Interviews with the facility staff, including the DON, Unit Manager (UM), and Assistant Director of Nursing (ADON), revealed confusion and lack of documentation regarding the resident's pain medication orders. The ADON could not recall why the medication order was changed days after the physician's visit, and the DON confirmed that the doses of pain medication administered were not recorded in the MAR. This lack of accurate documentation and timely implementation of physician orders led to the resident experiencing unmanaged pain and highlighted significant deficiencies in the facility's medication management and documentation practices.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain safe infection control practices for Resident #200, who was on Enhanced Barrier Precautions (EBP) due to chronic macerated wounds and a Foley catheter. During an observation, a CNA and an LPN were seen handling the resident's catheter bag and transferring the resident without wearing the required PPE, such as gowns and goggles. Additionally, the CNA did not perform hand hygiene after removing gloves, and there was no PPE cart in sight. The resident had multiple superficial open wounds on his thighs that were not adequately covered by dressings, and the staff continued to handle the resident and his equipment without changing gloves or donning additional PPE, even when the resident had a bowel movement and required assistance with a bedpan. Interviews with staff revealed a lack of awareness and adherence to the EBP requirements. One CNA was unaware of the reason for the EBP and noted that gowns were not available in the resident's room. The Director of Nursing confirmed that staff should wear gowns, gloves, and goggles when providing direct care to Resident #200, especially when managing his catheter bag. The failure to follow proper infection control protocols resulted in the potential for cross-contamination and the spread of multi-drug resistant bacteria.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near South Haven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Orchards At Douglas Cove | 17 mi | — | 2 | 0 |
| Ely Manor | 21.8 mi | — | 34 | 0 |
| Allegan County Medical Care Facility | 22.4 mi | — | 8 | 0 |
| Coventry House Inn | 25.7 mi | — | 14 | 0 |
| Royalton Manor, Llc | 25.9 mi | — | 5 | 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.