Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Madison during CMS and state inspections, most recent first.
Improper Thawing of Frozen Food: Surveyors observed fish thawing in a water bath and chicken patties thawing in a sink without running water. The FSM stated the facility policy allowed thawing in the refrigerator, under cold running water, or in the microwave for immediate use, but could not explain why the items were being thawed this way. The facility policy required frozen items to be thawed under refrigeration, in the microwave for immediate use, or in a sealed container immersed in cold running water.
Two residents were not supported in their personal choices. One resident with cognitive impairment and apraxia had repeated requests for a haircut that were not fulfilled, despite family, staff, and admin discussions, and the resident stated a preference for short hair. Another resident with fx of the R femur, anxiety, and parkinsonism had a family-reported intolerance to caffeinated coffee and requested decaf coffee or tea, but staff could not identify whether coffee served was regular or decaf, the beverage cart lacked a decaf option, and meal tickets did not clearly reflect the resident’s tea preference.
Failure to Document and Resolve Resident Grievances: A resident with MS, anxiety, and pain reported missing pants, but the concern was not documented in the grievance log and key staff were unaware of it, despite a laundry aide knowing about the issue. Another resident with brain cancer, apraxia, and moderate cognitive impairment had family concerns about poor personal care and a missed medical appointment, but the grievance process was incomplete, the personal care concerns were not included, and the responsible party was not updated.
Failure to Timely Report Allegation of Neglect: A resident with Parkinsonism, a fractured femur, and significant ADL assistance needs was alleged to have been left in a dirty brief overnight after requesting toileting help and being told to use the diaper because staff were too busy. The concern was reported to an MD and an unidentified nurse, but the RN supervisor denied being notified, and the facility did not submit the reportable event to the SA within the required timeframe.
Failure to Investigate Allegation of Neglect: A resident with intact cognition, a right femur fracture, and Parkinson’s disease was reportedly told to use a diaper instead of receiving toileting help and was left in a dirty brief overnight. The family raised the concern to the MD and a nurse, but the allegation was not promptly reported or investigated, and the DON could not explain why the issue was not addressed earlier.
Improper removal of post-surgical wound vac: A resident admitted with a lumbar surgical incision, DM2, and HTN had a wound vac documented on admission. Staff removed the wound vac based on an order to leave the dressing intact until a later date and then open to air, despite no wound vac removal order in the record and the resident/family stating the surgeon wanted it left in place until follow-up. The RN acknowledged he assumed the device should be discontinued and removed it without confirming orders, and the facility had no wound vac policy to guide care.
Failure to Obtain Orders for Wound Vac Care: A resident admitted after spine surgery had a lumbar incision and wound vac documented on admission, but the chart lacked clear MD orders for wound vac care. The admitting nurse entered an order to leave the wound open to air, the wound vac was removed before the first wound eval, and the resident and family reported the wound was not cared for daily and that the resident was left in wet, bloody linens. The wound nurse stated the transfer paperwork did not include the wound vac and that the wound was open to air for several days before APRN wound orders were written.
Failure to Offload Heels and Report Skin Changes: A resident at risk for skin breakdown had care plan interventions for heel offloading, skin prep, and a pressure-reducing mattress, but staff repeatedly observed the heels not offloaded and the bed too short. A nurse aide noticed reddened heel areas, yet licensed staff did not assess or document the change for several days. When the wound was finally evaluated, the resident had a new non-blanchable left heel pressure injury, and interviews confirmed no pressure-reducing mattress had been placed despite charting that it was in use.
A resident with CKD and ESRD had scheduled dialysis treatments and was supposed to return with a communication form documenting post-treatment vitals, weight, and any new orders. Review of the record showed 71 missing communication forms out of 120 treatments, and there was no EHR documentation that the center was contacted when forms were missing. An LPN, an RN supervisor, and the DON all described the expected communication process, while the dialysis center nurse stated the resident attended scheduled treatments and no forms had been received from the LTC facility.
Unsecured medications and controlled substances were found in two medication storage areas. An LPN left discontinued Levothyroxine and Doxycycline tablets unattended on a nurse’s station counter while residents were present on the unit, and two medication room refrigerator narcotic boxes were not secured to the refrigerators and were left unlocked, including one containing Lorazepam.
A resident was discharged with a bag of meds that belonged to two other residents, exposing their PHI. RN said she gave the wrong meds because she did not read the labels due to not wearing her glasses, and she did not notify the affected residents. The DON stated the incident had not been reported before staff discussion was overheard, and the facility had no policy for protecting health information.
Glucometer Not Properly Disinfected Between Residents: An RN used a glucose meter on two residents with diabetes and cleaned it with a wipe from a container labeled as hand sanitizer instead of the correct disinfectant. After testing the second resident, the RN left the meter on a paper towel on the med cart and later stored it without disinfecting it. The DON stated the correct wipes were purple-top disinfection wipes or bleach per the manufacturer, and the facility policy required disinfection after each use.
The facility failed to notify the responsible party timely when a resident developed a new deep tissue injury (DTI). Despite the resident's high risk for skin breakdown and the facility's policy requiring immediate notification, the charge nurse did not document or recall notifying the family. The Director of Nursing confirmed the necessity of such notifications but could not provide evidence that it was done.
A facility failed to maintain complete and accurate medical records for a resident receiving end-of-life care. The records lacked documentation of ADL care, hospice services, and the assessment at the time of death due to a change in ownership and missing records from the prior owner.
The facility failed to prevent and treat pressure ulcers for two residents. One resident developed an unstageable pressure ulcer due to inadequate repositioning and off-loading, while another resident's new pressure ulcer was not properly assessed or treated. Staff did not adhere to policies, and documentation was inconsistent.
The facility failed to adequately staff NAs, resulting in unmet care needs for residents. One resident with dementia was observed with poor hygiene due to insufficient staffing. Another resident with Alzheimer's had long, dirty nails, and a third resident with Down Syndrome was inadequately supervised, leading to unsafe behavior. Staff interviews and facility records confirmed frequent understaffing and restricted use of agency staff.
The facility failed to provide adequate snacks for residents during a 15-hour gap between dinner and breakfast. Snacks were only given upon request and were insufficient, with some units not receiving snack carts for weeks, contrary to facility policy.
The facility failed to follow infection control practices, leaving a resident's room in disarray and lacking required policies for undiagnosed respiratory illness and early detection of potentially infectious residents. This indicates significant gaps in the facility's infection control program.
The facility failed to adequately respond to resident grievances, including early supper meal times, lack of alternative meal choices, and staff discussing personal information loudly. Despite being aware of these issues, the facility did not take effective action to resolve them.
The facility failed to maintain a clean, comfortable, and homelike environment. Observations revealed trash on floors, deteriorated window seats, and broken wood molding in resident rooms. Interviews indicated that maintenance relied on staff notifications for repairs and did not perform routine audits. The facility also lacked an environmental condition and/or repair policy.
The facility failed to provide adequate personal hygiene care to several residents, resulting in long, soiled fingernails and unshaven facial hair. Staff cited staffing shortages and dull razors as reasons for the neglect, and nursing notes did not document any refusal of care by the residents.
The facility failed to label oxygen tubing for residents requiring oxygen therapy, despite physician orders. Multiple residents with conditions such as COPD, anoxic brain damage, and dementia were observed with unlabeled oxygen tubing. Staff confirmed the tubing was not labeled and did not routinely change it as required.
The facility failed to complete annual performance appraisals for two nurse aides. One aide's last appraisal was not dated, and another's was five years old. The Administrator cited inconsistent staffing and multiple changes in the DNS position as reasons for the lapse. Facility policy mandates annual appraisals and in-service education based on these reviews.
The facility failed to ensure behavior monitoring for two residents receiving psychotropic medications. One resident with dementia and agitation was prescribed Risperidone, and another with Down Syndrome and Alzheimer's was prescribed Olanzapine. In both cases, there was no documented behavior monitoring, contrary to facility policy.
The facility failed to provide dental services for a resident with significant medical conditions, despite multiple evaluations indicating the need for a dental consult. The resident had not seen a dentist since admission over a year and eight months ago, and the required permission forms were not completed by the admitting nurse.
The facility failed to ensure safe water temperatures in resident areas, with multiple instances of bathroom sink water temperatures exceeding the safe limit of 120 degrees Fahrenheit. The Director of Maintenance did not follow the facility's policy for monitoring and adjusting water temperatures and failed to notify the Administrator of the excessive temperatures.
The facility failed to ensure that two nurse aides completed the mandatory 12 hours of in-service education annually, including dementia care training. The training records were incomplete, and the facility could not provide an annual in-service training policy.
A resident with a suprapubic catheter was observed in the dining area with an exposed urinary collection bag. The OT assisting the resident was unaware of the need for a privacy cover, and the DNS confirmed the policy but could not provide a written document.
The facility failed to ensure accurate documentation and updating of advance directives for three residents. Discrepancies were found in the code status of one resident, while two others lacked documented advance directives upon admission. Staff interviews revealed confusion and lack of clarity regarding responsibilities for updating records.
A resident with dementia and other health issues experienced significant weight loss over three months. The facility failed to notify the resident's representative, and the dietician confirmed the lack of a specific policy for such notifications, highlighting a systemic communication issue.
A resident with Down Syndrome and Alzheimer's was found restrained to their wheelchair with a bed sheet due to insufficient staffing and inadequate supervision. The restraint was discovered by an SLP, who reported the incident, revealing ongoing staffing issues and inadequate behavioral interventions in the care plan.
A resident with multiple diagnoses, including Down Syndrome and Alzheimer's, was found restrained to a wheelchair by a bed sheet. The incident, admitted by a nursing assistant, was not reported to managerial staff until three days later, and the Administrator delayed reporting to the state agency, citing a lack of information from a witness. This delay violated the facility's abuse reporting policy.
The facility failed to update and implement new interventions in the care plans for several residents following significant events, including falls and the development of pressure ulcers. Care plans were not revised to reflect increased needs or to prevent further incidents, leading to inadequate care and safety measures.
The facility failed to provide appropriate foot care for a resident with chronic kidney disease, total hip arthroplasty, and gout. Despite a physician's order to consult podiatry as needed and multiple requests for foot care, no referral was made. Observations revealed the resident's toenails were long and curling forward, and the facility's Foot Care policy was not followed.
The facility failed to implement care plan interventions, provide adequate supervision, and conduct risk assessments following falls for three residents. Despite being identified as fall risks, the residents experienced unwitnessed falls due to inadequate monitoring and non-compliance with fall protocols.
The facility failed to notify the Ombudsman regarding multiple hospital transfers of a resident with heart failure, anemia, and dementia. Despite several medical emergencies requiring hospital transfers, the facility did not follow its policy for timely notification, as confirmed by interviews with the Social Worker and the Ombudsman.
The facility failed to notify a resident's representative in writing about the bed hold policy during multiple hospital transfers, despite the resident's moderate cognitive impairment and need for assistance. The Business Office Manager acknowledged the oversight, noting a recent shift in responsibility for completing the notifications.
Improper Thawing of Frozen Food
Penalty
Summary
The facility failed to ensure frozen food was thawed according to its policy and professional standards. During the initial kitchen tour on 8/15/2025 at 9:38 AM, surveyors observed fish thawing on one side of a double sink in a water bath and chicken patties on the other side of the sink in a plastic package without any running water being used. On 8/19/2025 at 11:32 AM, the Food Service Manager stated the fish had been in a water bath and that he drained the water with the fish in it. He also stated the facility policy allowed thawing frozen food in the refrigerator, under cold running water, or in the microwave for immediate use, but he could not determine why the cook had the fish in a water bath or why the chicken patties were being thawed without running water. Review of the Food Storage Cold policy dated May 2014 confirmed frozen items were to be thawed under refrigeration, in the microwave for immediate use, or in a sealed container immersed in cold running water.
Failure to Honor Resident Choice for Grooming and Beverage Preferences
Penalty
Summary
The facility failed to honor resident choice for two residents by not supporting their personal preferences and requests. Resident #33 had diagnoses including malignant neoplasm of the frontal lobe, atherosclerosis of bilateral extremities, and apraxia, with a BIMS score of 10 indicating moderate cognitive impairment and dependence on staff for personal hygiene, oral hygiene, and dressing. The resident’s care plan identified a communication problem related to unclear speech, and the responsible party reported that the resident had been seen with long, greasy hair during medical appointments and that repeated requests for a haircut had been made to social services, nursing staff, and the business office over the prior months. Observations over several days showed Resident #33 with slicked back hair extending about 3 inches below the nape of the neck. The resident stated a preference for short hair. The Administrator stated a family meeting had been held to address care concerns, including the haircut request, but the haircut had not been provided because she believed the hairdresser might not be comfortable cutting the resident’s hair due to neck positioning and suggested nursing assistants or hospice could provide the haircut. The hairdresser stated she was notified by written request when a resident wanted a haircut, but she could not recall receiving a request for Resident #33 and could not find one in her records. The Business Office Manager stated the responsible party submitted a haircut request that was passed on to the hairdresser, but she could not provide a copy of the request or recall when it was written. Resident #58 had diagnoses including fracture of the right femur, anxiety, and parkinsonism. The resident’s assessments showed varying cognitive and functional findings, and the care plan identified nutritional risk with interventions to serve the ordered diet and monitor intake. The resident’s family member reported that caffeinated coffee made the resident violently ill and that decaf coffee and tea had been requested, but staff repeatedly could not identify whether the coffee served was regular or decaf, so the resident could not drink coffee at meals. Observation confirmed staff served an unknown type of coffee and could not tell the family member whether it was regular or decaf. The NA stated she did not know the type of coffee in the carafe and that the beverage cart had no decaf coffee option, while the Dietary Director stated all residents were served regular coffee from the carafe and that decaf was only available as instant coffee packets, not in a carafe. Review of the resident’s menu selections showed tea had been requested as the beverage of choice, but the printed meal tickets did not identify the tea request and instead directed either tea or coffee.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to follow its grievance policy for a resident with multiple sclerosis, anxiety, pain, and no cognitive impairment who reported missing pants. The resident told surveyors that laundry personnel had been informed, but no response was received. Review of the resident’s nurse’s notes and the grievance log for July and August 2025 did not identify any documentation of the missing item. Interviews showed the social worker and RN were not informed, while a laundry aide stated she knew about the missing pants, had tried to locate them, and had told a prior district director of laundry and housekeeping. The facility also failed to properly document and resolve concerns raised by a resident with malignant neoplasm of the frontal lobe, atherosclerosis of bilateral extremities, apraxia, and moderate cognitive impairment. The resident’s responsible party reported worsening personal care, including disheveled appearance, dirty hair, dirty fingernails, and food in the resident’s teeth, along with a missed medical appointment and poor communication from the facility. A meeting was held with the responsible party and facility leadership, but the responsible party stated no grievance form was completed or signed during that meeting, and the grievance book and logs did not show the concerns were documented. Facility interviews and record review showed the Administrator was the grievance officer and stated that complaints from residents or family members were to be documented on a grievance form and tracked to resolution. The Administrator acknowledged receiving concerns about personal care and transportation, and a grievance had been initiated for missed transportation, but it did not include the personal care concerns. The Administrator also stated the responsible party was not updated on the grievance resolution because it remained incomplete on her desk.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Agency within the required 24-hour timeframe for one resident. The resident had diagnoses including fracture of the right femur, anxiety, and parkinsonism. The admission MDS identified a BIMS score of 14, indicating intact cognition, and the resident required maximal assistance for toileting and chair/bed-to-chair transfers and was dependent for personal hygiene. The care plan identified Parkinson’s disease, and the NA care card directed extensive assist of 2 staff for repositioning and turning in bed. A family member reported that during the night shift the resident rang for toileting assistance after midnight and was told to poop in the diaper because the aide was too busy, and the resident remained in a dirty brief overnight and felt disrespected. The family member said the concern was voiced to an unknown nurse and to the MD on the morning of the same day. The MD stated he notified the nursing supervisor of the allegation of neglect and that nursing was responsible for follow-up, but the RN supervisor denied being made aware of the allegation. The facility did not generate the reportable event document until after surveyor inquiry, and the DNS could not explain why she was not notified earlier or why the report had not been sent immediately after the allegation was reported.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to investigate an allegation of neglect involving a resident with a right femur fracture, anxiety, and parkinsonism. The resident’s MDS showed a BIMS score of 14, indicating intact cognition, and the care plan identified Parkinson’s disease with interventions to monitor for complications such as gait disturbance, incontinence, skin breakdown, and decline in cognitive function. The NA care card directed extensive assistance of 2 staff for repositioning and turning in bed. A family member reported that during the night shift the resident rang for toileting assistance and was told to poop in the diaper because the aide was too busy, and that the resident remained in a dirty brief overnight and felt disrespected. The family member said the concern was voiced to an unknown nurse and the MD, and the MD stated he notified the nursing supervisor and expected the Nursing Department to follow up. The supervisor denied being informed of the allegation, and the facility did not generate a reportable event or begin an investigation until after surveyor inquiry, with the Administrator stating the investigation was still incomplete and the DON unable to explain why she had not been notified earlier.
Improper removal of post-surgical wound vac
Penalty
Summary
The facility failed to follow professional standards of care for the utilization of a post-surgically placed wound vac for Resident #43, who was admitted with diagnoses including fusion of the spine, type 2 diabetes, and hypertension. The admission assessment documented intact cognition, a surgical incision to the lumbar back, and need for supervision with transfers and walking. The admission skin assessment and baseline care plan identified a lumbar incision with a wound vac. A physician order directed the dressing to remain clean, dry, and intact, to be left intact until 8/4/2025, and then opened to air, with sutures and staples to be removed on post-operative day 14. During observation and interview, the resident and family member stated the surgeon had directed that the wound vac remain in place until the resident was seen by the surgeon, but it had been removed by the facility. The hospital discharge summary and interagency transfer documents did not include the wound vac placement. The Infection Preventionist/RN stated he assumed the wound vac was to be discontinued because the order said open to air, and he removed it without confirming any wound vac orders. He acknowledged there were no orders in the record directing removal and that he should have contacted a provider or the surgeon before removing it. The facility also did not have a wound vac policy to guide staff care for residents admitted with a wound vac.
Failure to Obtain Orders for Wound Vac Care
Penalty
Summary
The facility failed to obtain physician orders to direct care for a wound vac for a post-surgical resident with fusion of the spine, type 2 diabetes, and hypertension. On admission, the resident had a surgical incision to the lumbar region, intact cognition, and required supervision with transfers and walking. The admission skin assessment and baseline care plan identified a lumbar incision and a wound vac, and the care plan included keeping the skin clean and dry, monitoring for infection, and monitoring nutritional status. The clinical record showed a physician order to keep the dressing clean, dry, and intact until 8/4/2025, then leave it open to air, and an APRN order later directed cleansing the incision with Betadine and covering it with a dressing every 8 hours and as needed. During observation and interview, the resident and family member stated the surgeon had directed that the wound vac should have remained in place until the surgeon saw the resident, and they reported wound care was not performed daily, leaving the resident in wet, bloody sheets and a wet shirt. The bed sheet was observed to have dried yellow stains in the area of the wound. Review of the hospital discharge summary and transfer documents did not include the wound vac placement. The Infection Preventionist/Wound Nurse stated he could not locate physician or hospital wound care orders on admission, that the admitting nurse entered an order for the wound to remain open to air beginning 8/4/2025, and that he removed the wound vac on 8/4/2025 before the first APRN wound evaluation on 8/7/2025. He stated he was not notified of the large amount of drainage after removal, and that the wound being open to air from 8/4/2025 through 8/7/2025 increased the likelihood of delayed healing and risk of infection. He also stated the admitting nurse should have reviewed the hospital discharge summary and transfer instructions and clarified wound vac care when no orders were available.
Failure to Offload Heels and Report Skin Changes
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions for a resident admitted with diagnoses including fracture of the right femur, anxiety, and parkinsonism. The admission nursing assessment found the resident’s skin normal with no pressure ulcers or deep tissue injuries, and the care plan identified the resident as at risk for skin breakdown related to impaired mobility. The care plan and MD orders required heel offloading, skin prep to both heels, monitoring for skin changes every shift, and a pressure reducing mattress, but observations later showed the resident’s heels were not consistently offloaded and the bed was too short for the resident. On 8/15/2025, a nurse aide observed the resident’s feet at the end of the bed with the sheets tucked tightly under the mattress and the heels not offloaded. The family member reported that staff had told them the resident had reddened heel areas that needed treatment and that special boots were ordered for nighttime use. Despite this, licensed staff did not document or assess the change in skin integrity until 8/19/2025, four days later, when a nurse noted a new dark reddish-purple non-blanchable area on the left heel. The wound care nurse later assessed the heel as a new stage 1 pressure ulcer with boggy peri-wound tissue. Additional observations showed the resident repeatedly lying in bed with the heels pressed against the footboard, without heel boots or a pressure reducing mattress in place. Staff documentation on the TAR indicated a pressure reducing mattress was in place, but multiple staff and maintenance interviews confirmed that no pressure reducing mattress had ever been placed in the resident’s room and that the bed had never been modified despite being too short. The facility’s pressure ulcer prevention policy required assessment after a change in condition or newly identified pressure injury, but staff failed to promptly report the skin change, failed to consistently offload the heels, and failed to ensure the ordered mattress was in place.
Missing dialysis communication with treatment center
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for a resident with chronic kidney failure and end stage renal disease by not communicating and collaborating with the specialized treatment center. The resident had a physician order for specialized treatments three days a week, was cognitively intact, and required supervision and touching assistance for chair-to-bed transfers. The care plan identified the resident as at risk for impaired renal function and complications related to specialized treatments, with interventions to monitor the access device for bruit and thrill, monitor for fatigue or weakness, and provide a renal diet as ordered. Review of the resident’s clinical record and communication book from 11/13/24 to 8/15/25 showed several missing communication records. The electronic health record did not identify that the specialized treatment center had been contacted regarding the missing communication documentation. LPN #2 stated the process was to obtain vital signs before transport, send a communication form with the resident, and receive the form back from the treatment center with post-treatment vital signs, weight, and any new recommendations or orders. LPN #2 also stated that if the resident returned without a communication form, the nurse should call the center and document the contact in a nursing note. LPN #2 identified that the resident’s specialized communication binder was missing 71 communication forms out of 120 attended treatments, and there was no nursing documentation showing the center was contacted about the missing information. RN #2 gave the same account of the expected process and also confirmed there was no documentation that the center had been called. The specialized treatment center nurse stated the resident attended scheduled treatments and that, to her knowledge, no communication forms had been received from the LTC facility for the resident. The DON stated that residents should return with the communication form and that if they did not, the unit nurse or nurse supervisor was responsible to contact the center for post-treatment information. The facility policy stated it would assure ongoing communication and collaboration with the treatment facility regarding care and services.
Unsecured Medications and Controlled Substances
Penalty
Summary
Drugs and biologicals were not properly stored on the Tunxis Unit when Levothyroxine Sodium 200 mcg tablets and Doxycycline Hyclate 100 mg tablets were found unattended on the nurse’s station counter. No staff were present in the area at the time, residents could be seen on the unit, and the nurse’s station door was open. An LPN stated she had removed the medications because they were no longer needed for the residents to whom they had been prescribed and intended to discard them, but had left them on the counter and forgot to secure or discard them appropriately. Review of the medication records showed the Doxycycline order for one resident had ended three days earlier, and the Levothyroxine order for another resident had been discontinued with a different active dose ordered to begin the same day as the observation. The unit manager stated the medications should not have been left unattended and unsecured and that once removed from the cart for discard, they should have been taken directly to the medication storage room and placed in the discard medication area. Controlled substances were also not properly secured in two medication storage rooms. On the Tunxis Unit and the [NAME] Point Unit, the narcotic medication boxes inside the medication room refrigerators were affixed to removable shelves but were not secured to the refrigerators, and the boxes were unlocked. One box contained three boxes of Lorazepam 2 mg/ml, a schedule IV controlled substance. Staff and the DON were unable to explain why the boxes were not secured, and the DON stated the boxes could be removed from the refrigerators without difficulty.
Improper release of resident medication information at discharge
Penalty
Summary
The facility failed to ensure protected personal information remained secured and private when a discharged resident was sent home with medications belonging to two other residents. After Resident #43’s discharge, the resident’s family member reported receiving a bag of prescriptions from RN #1 that contained medications labeled for Resident #48 and Resident #89. Photographs showed a bag labeled with Resident #48’s name, date of birth, and medical record number, along with Dorzolamide-Timolol eye drops, Pilocarpine eye drops, and Megestrol Acetate oral suspension labeled with Resident #48’s full name and prescription information, as well as Breyna inhalation aerosol labeled with Resident #89’s full name and prescription information. Resident #43 had diagnoses including fusion of the lumbar spine, type 2 diabetes, and hypertension, and review of the physician orders did not show that any of the medications from Residents #48 or #89 had been prescribed for Resident #43. Resident #48 had diagnoses including glaucoma and cancers of the lung and bone, with orders for Dorzolamide HCL-Timolol, Megestrol Acetate, and Pilocarpine HCL that matched the medications sent home. Resident #89 had diagnoses including asthma, type 2 diabetes, and COPD, with an order for Budesonide-Formoterol Fumarate inhalation aerosol that matched the Breyna medication sent home. RN #1 stated she was responsible for sending the incorrect medications home and had not read the bottles because she was not wearing her glasses, and she did not think to notify Residents #48 or #89 that their protected personal information had been provided to an unauthorized individual. The DNS stated staff and the Administrator had not reported the incident prior to overhearing staff discussing it, and the facility did not have a policy for protecting health information.
Glucometer Not Properly Disinfected Between Residents
Penalty
Summary
The facility failed to clean and disinfect a glucometer per the manufacturer's instructions for use for 2 of 2 residents reviewed for blood glucose testing, Resident #83 and Resident #89. Resident #83 had diagnoses including type 2 diabetes, hypertension, and osteoarthritis, was cognitively intact with a BIMS score of 15, and had orders for fingerstick blood glucose monitoring and lispro insulin before meals and at bedtime. During observation, RN #5 performed Resident #83's blood sugar check and then cleaned the glucose meter with a wipe taken from a blue-top container labeled Antimicrobial Hand Sanitizer, alcohol 67.9%. RN #5 stated she believed the wipe was the correct one for disinfecting glucose monitors and said the unit nurse was responsible for ensuring the correct wipes were used. RN #5 then used the same glucose monitor for Resident #89, who had diagnoses including type 2 diabetes, COPD, and systemic lupus erythematosus, with a BIMS score of 10 and moderate assistance needs for personal hygiene and bed mobility. After testing Resident #89, RN #5 placed the glucose monitor on a paper towel on top of the medication cart and left it there during constant observation until she later stored it in a drawer without disinfecting it. RN #5 stated she had been unaware that the meter had not been appropriately cleansed before being stored. The DNS stated the correct wipes for the glucometer were purple-top disinfection wipes or a bleach wipe per the manufacturer's recommendations and that glucometers should always be cleaned between residents, but could not explain why RN #5 failed to use the correct wipes and failed to clean the meter between residents. The facility policy stated glucometers should be disinfected after each use with a disposable germicidal wipe, or with alcohol prep pad followed by 1:10 bleach if germicidal wipes were unavailable.
Failure to Notify Responsible Party of Change in Skin Integrity
Penalty
Summary
The facility failed to ensure the responsible party was notified timely when a change in skin integrity was identified for Resident #1. Resident #1, who was admitted with diagnoses including schizoaffective disorder, generalized muscle weakness, and senile degeneration of the brain, was at risk for skin breakdown due to inadequate oral intake, fragile skin, incontinence, and limited mobility. Despite interventions such as floating heels while in bed and using a low-loss mattress, a deep tissue injury (DTI) was identified on Resident #1's right foot by a wound Nurse Practitioner (NP) on 10/23/2023. However, the clinical record review failed to show that the responsible party was notified of this new DTI. Interviews with the infection control/wound nurse and the charge nurse revealed that the charge nurse was responsible for notifying the family and documenting the notification in the clinical record. The charge nurse on duty at the time of the DTI identification could not recall if the family was notified and acknowledged that if it was not documented, it was not done. The Director of Nursing (DON) confirmed that notification to the physician and family was necessary for new pressure areas but was unable to provide documentation that the family was notified. The facility's policy on Change in Condition: Notification of, dated 6/1/2021, directed that the facility must immediately inform the resident's health care authority or Health Care Decision Maker of significant changes in the resident's physical status or the need to commence new treatment.
Incomplete Medical Records and Documentation for End-of-Life Care
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was receiving end-of-life care. The resident, who had diagnoses including schizoaffective disorder, generalized muscle weakness, and senile degeneration of the brain, was at risk for skin breakdown and had a Stage III pressure ulcer. However, the facility did not have documentation of Activities of Daily Living (ADL) care for a specific period due to a change in ownership, and the requested documentation from the prior owners was not available for review. This lack of documentation was against the facility's ADL policy, which required real-time recording of ADL care in the medical record. Additionally, the resident was on hospice services, but the medical record lacked the hospice election form and documentation of hospice services provided during a specific month. The facility's hospice policy required obtaining the hospice election form and documenting all hospice care provided. The Director of Nursing (DON) acknowledged the missing documentation and indicated that a request had been made to the prior owner's corporate office and the hospice service provider to obtain the necessary records. Furthermore, the facility failed to document the assessment of the resident at the time of death. Although a registered nurse (RN) pronounced the resident's death and notified the family, the RN did not document the assessment criteria used to determine death, as required by the facility's Pronouncement of Death policy. The policy mandated detailed documentation of the clinical criteria for pronouncing death, including vital signs, pupil reaction, and other physical assessments. The DON confirmed that the facility did not have access to the prior owner's electronic medical records and had requested the missing documentation.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of pressure ulcers and provide necessary treatment for two residents. For Resident #9, the facility did not ensure timely turning, repositioning, and off-loading of heels, failed to conduct pressure ulcer risk assessments per policy, and did not perform weekly skin assessments. Despite Resident #9's decline in condition due to pneumonia and urinary tract infection, the care plan was not updated to reflect the increased need for assistance. This led to the development of an unstageable pressure ulcer on the left heel, which worsened over time due to inadequate off-loading and repositioning by staff. For Resident #62, the facility failed to conduct an initial pressure ulcer assessment, obtain initial measurements, inform the wound nurse of the new pressure ulcer, and ensure off-loading of the pressure area. Despite a physician's order for heel boots at all times, Resident #62 was observed without heel boots on multiple occasions. The facility's documentation did not reflect the presence of a new pressure ulcer, and the wound nurse was not informed, leading to a lack of appropriate treatment and monitoring. Interviews with staff revealed a lack of adherence to the facility's policies and procedures for pressure ulcer prevention and care. Staff failed to implement new interventions when residents' conditions changed, did not conduct required assessments, and did not ensure proper off-loading of pressure areas. The facility's documentation was inconsistent and did not accurately reflect the residents' needs or the care provided, contributing to the development and worsening of pressure ulcers in both residents.
Inadequate Staffing Leads to Unmet Resident Care Needs
Penalty
Summary
The facility failed to adequately staff Nurse Aides (NAs) throughout the facility, resulting in unmet resident care needs. Resident #21, diagnosed with dementia and heart disease, was observed with long, dirty fingernails and unshaven facial hair, indicating a lack of personal hygiene care. Despite requiring extensive assistance, the resident's hygiene needs were not met due to insufficient staffing, as confirmed by NA #2, who stated that hygiene tasks were often neglected when the facility was understaffed. The facility's documentation and interviews revealed that the required number of staff was rarely met, leading to compromised care for residents like Resident #21. Resident #53, diagnosed with Alzheimer's disease and major depressive disorder, was also observed with long, jagged nails and dried blood on their hands. Despite the care plan indicating the need for extensive assistance with personal hygiene, the resident's nails remained untrimmed and dirty. Interviews with NAs revealed that nail care and other hygiene tasks were only completed when the facility was fully staffed, which was not often the case. The NAs reported having assignments of up to 12 residents when short-staffed, making it difficult to provide adequate care. Resident #527, diagnosed with Down Syndrome and Alzheimer's Disease, exhibited behaviors such as disrobing and attempting to self-transfer, requiring close supervision. However, due to staffing shortages, the resident was not adequately monitored, leading to incidents of self-harm and unsafe behavior. On one occasion, an NA resorted to restraining the resident with a bed sheet due to the inability to provide proper supervision. Interviews with staff and review of facility records confirmed that the unit was frequently understaffed, with managerial staff acknowledging the lack of sufficient personnel to meet the residents' needs. The facility's corporate policies further restricted the use of agency staff, exacerbating the staffing issues and compromising resident care.
Inadequate Snack Provision for Residents
Penalty
Summary
The facility failed to provide adequate snacks for residents when mealtimes exceeded 14 hours. Observations and interviews with residents revealed that snacks were only provided upon request and consisted of small items such as cookies, cookie bars, applesauce, or juice, which residents did not consider adequate or substantive. The meal schedule showed a 15-hour gap between dinner at 4:30 PM and breakfast at 7:30 AM, during which residents were not provided with sufficient nourishment. Interviews with dietary staff and nursing aides indicated inconsistencies in the delivery of snack carts to the units, with some units not receiving snack carts for weeks at a time. The facility's policy stated that evening snacks should be planned as part of the menu and that stock foods should be stored for use on nursing units. However, observations and staff interviews confirmed that this policy was not being followed, leading to residents not receiving the necessary nourishment during long gaps between meals.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow infection control practices on one of its units, specifically in the case of Resident #53. Resident #53, who has Alzheimer's disease, cognitive communication deficit, and inflammatory polyarthropathy, was observed in a room with a full trash can on the bedside chair and soiled linens and incontinent pads on the floor. The resident's care plan indicated they required extensive assistance with activities of daily living, including bed mobility, dressing, personal hygiene, and bathing. A housekeeper confirmed that the room should not have been left in such a state and suggested that staff often leave rooms messy, making it difficult for her to maintain cleanliness given her workload of 40 rooms per shift. This indicates a lapse in maintaining a clean environment for the resident, which is crucial for infection control. Additionally, the facility's infection control program was found lacking required policies for undiagnosed respiratory illness and a plan for early detection and management of potentially infectious residents. During an interview, a registered nurse was unable to locate these policies or provide guidance on them, and neither she nor the Director of Nursing Services could find the missing policies. The facility's Infection Control Outcome and Process Surveillance and Reporting policy, last revised on 2/1/23, mandates regular surveillance and compliance monitoring, but the absence of these critical policies indicates a significant gap in the facility's infection control program.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately respond to resident grievances as identified in the Resident Council meeting minutes. Residents expressed concerns about the early arrival of supper meals and the lack of alternative meal choices. Despite these concerns being documented and communicated to the dietary staff, the issue persisted. Additionally, residents reported that they were left in bed until lunch due to staffing shortages, and their beds were not made or changed after they got up. Staff were also heard discussing personal information loudly in the hallways and using inappropriate language. These issues were raised multiple times in Resident Council meetings, but the facility did not take effective action to resolve them. Interviews with the Director of Dietary and the Director of Nursing Services (DNS) revealed awareness of the issues but highlighted systemic problems such as the lack of a Human Resources staff member and restrictions on using agency staff due to cost. The DNS admitted that the facility was aware of the staffing issues but had not been informed about the specific concern regarding the early arrival of dinner. The Director of Dietary acknowledged the problem but indicated that it persisted when a manager was not present. The facility's grievance policy mandates prompt investigation and resolution of concerns, which was not adequately followed in this case.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure equipment and furniture were maintained in a clean, comfortable, and homelike manner. During an initial facility tour, trash was observed on the floors in the hallways and in several resident rooms. In one room, a medicine cup with white powder was found on the floor, and used medical gloves were seen in flower boxes. Additionally, a piece of wood molding under a window seat was broken, exposing a sharp edge. Multiple rooms had window seats that were significantly deteriorated, with cracked, peeling, and discolored padding, and worn wood cabinets with no protective finish. Interviews with the Director of Maintenance and the Maintenance Assistant revealed that maintenance was responsible for maintaining the furnishings but relied on staff to notify them of needed repairs. The Director of Maintenance was unaware of the disrepair in certain rooms and indicated that routine audits or rounds to observe room conditions were not performed. The facility also failed to provide an environmental condition and/or repair policy when requested.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to ensure personal hygiene care and services were provided to dependent residents, as evidenced by observations and interviews. Resident #21, diagnosed with dementia and heart disease, was observed with dark debris under fingernails and long facial hair on multiple occasions. Despite being identified as requiring assistance with personal hygiene, staff interviews revealed that hygiene tasks were often neglected due to staffing issues. Nursing notes did not indicate any refusal of care by the resident during the observed period. Resident #27, with severe cognitive impairment and cancer, was also found with dark debris under fingernails and long facial hair. Observations and staff interviews indicated that the resident's hygiene needs were not met, and staff cited dull razors and staffing shortages as reasons for the neglect. Nursing notes did not document any refusal of care by the resident. Similar issues were observed with Resident #46, who had long, soiled fingernails and substantial facial hair growth, and Resident #53, who had long, jagged nails with dark debris and dried blood. Resident #69, diagnosed with Alzheimer's disease and dementia, was observed with long fingernails and caked-on dark orange material in facial hair. Despite being totally dependent on staff for personal hygiene, the resident's needs were not met. Staff interviews confirmed that hygiene care was often delayed or neglected due to staffing shortages. Nursing notes did not indicate any refusal of care by the resident. The facility's policies on fingernail care and shaving were not adhered to, contributing to the deficiencies observed.
Failure to Label Oxygen Tubing
Penalty
Summary
The facility failed to appropriately label oxygen tubing for residents requiring oxygen therapy. Resident #4, diagnosed with anoxic brain damage and other conditions, was observed with unlabeled oxygen tubing despite a physician's order specifying oxygen administration at 2 liters per minute. Similarly, Resident #51, who has COPD and obstructive sleep apnea, was found with unlabeled oxygen tubing, contrary to the physician's order to change and label the tubing weekly. LPN #1 confirmed the tubing was not labeled and subsequently changed it after surveyor inquiry. Resident #57, with non-rheumatic aortic valve insufficiency and dementia, was also observed with unlabeled oxygen tubing, despite a physician's order for oxygen administration as needed. Additionally, Resident #279, diagnosed with COPD and heart failure, reported that staff did not routinely change the oxygen tubing, which was confirmed by RN #1. The facility did not provide a policy for oxygen equipment when requested, indicating a systemic issue in adhering to proper oxygen therapy protocols.
Failure to Complete Annual Performance Appraisals
Penalty
Summary
The facility failed to complete annual performance appraisals for two nurse aides, NA #10 and NA #11. NA #10's last performance appraisal was not dated by either the nurse aide or the next level manager, while NA #11's last performance appraisal was dated five years ago. The Administrator acknowledged the lapse, attributing it to inconsistent staffing and multiple changes in the Director of Nursing (DNS) position. The current DNS was attempting to catch up on tasks left incomplete by previous staff. According to the facility's policy, managers are required to conduct performance appraisals or performance-based conversations with employees at least annually, and in-service education should be provided based on these reviews.
Failure to Monitor Behaviors for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that behavior monitoring was completed for a resident receiving psychotropic medications. Resident #62, diagnosed with dementia with agitation, anxiety, and paranoid personality disorder, was prescribed Risperidone for agitation. Despite the care plan's directive to monitor for changes in mental status and functional level, no behavioral monitoring order was in place from 6/21/23 to 11/6/23. Nurse's notes and psychiatric notes lacked documentation of target behaviors or behavior monitoring, and interviews with staff confirmed the absence of such monitoring in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The Director of Nursing Services (DNS) acknowledged the lack of behavior monitoring and confirmed it was against facility policy, which mandates monitoring for residents on antipsychotic medications every shift. Similarly, Resident #527, admitted with Down Syndrome, Alzheimer's Disease, and diabetes mellitus, was prescribed Olanzapine for behavioral disturbance. The physician's order did not include behavioral monitoring, and a review of the MAR, TAR, and nurse's notes from 10/13/23 to 11/13/23 showed no evidence of behavior monitoring. The DNS confirmed that behavioral monitoring should be conducted for residents with dementia on antipsychotic medications without a psychiatric diagnosis, but was unable to locate any such documentation in the clinical record. The facility's policy on managing behavioral symptoms, which requires staff to monitor and document exhibited behavioral symptoms, was not followed. The lack of behavior monitoring for both residents receiving psychotropic medications indicates a failure to adhere to the facility's policies and procedures. This deficiency was identified through clinical record reviews, facility documentation, and staff interviews, highlighting a significant oversight in the care and monitoring of residents with behavioral and psychiatric needs.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for Resident #61, who was admitted with diagnoses including end-stage renal disease, right above knee amputation, and coronary artery disease. The Resident Care Plan dated 2/25/22 identified the resident as being at risk for oral health or dental care problems due to tooth decay, with interventions including obtaining a dental consultation. Despite oral health evaluations on 2/25/22 and 2/26/23 indicating a dental consult was ordered, the resident had not been seen by a dentist since admission over one year and eight months ago. The resident expressed a desire to see a dentist, and observations confirmed the presence of scattered broken and discolored teeth. Interviews with the Director of Nurses (DNS) and RN #4 revealed that the admitting nurse was responsible for ensuring permission forms for dental services were completed, which had not been done. The DNS confirmed that the resident had not received a dental consultation, and RN #4 indicated that if permission was not obtained on admission, the facility had 24 hours to complete the paperwork. The facility's dental service policy mandates routine dental services, including annual inspections of the oral cavity, which were not provided to Resident #61.
Failure to Ensure Safe Water Temperatures
Penalty
Summary
The facility failed to ensure safe water temperatures in resident areas, as observed on multiple occasions. On 10/31/23, the bathroom sink water temperatures for several residents were found to be significantly above the safe limit of 120 degrees Fahrenheit, with temperatures ranging from 122.6 to 127.0 degrees Fahrenheit. The Director of Maintenance confirmed these findings but believed that temperatures up to 124 degrees Fahrenheit were acceptable. However, the facility policy stated that water temperatures should be between 105 and 120 degrees Fahrenheit. The Director of Maintenance also failed to notify the Administrator of these excessive temperatures and did not follow the proper procedure for adjusting the water temperatures, instead opting to adjust the cold water to bring the hot water down. The Administrator was unaware of the excessive water temperatures until the surveyor's inquiry and confirmed that the water temperature logs from 10/14/23 showed nine resident rooms with temperatures above 120 degrees Fahrenheit. The Director of Maintenance was unable to provide a full month of water temperature logs, only producing logs for 10/14/23. The Administrator acknowledged that the Director of Maintenance had not adhered to the facility's policy for taking water temperatures and stated that she would address this issue with him. The facility's Hot Water Temperatures: Inspection policy, last revised on 6/1/23, directed that hot water temperatures should be tested weekly and documented, but this procedure was not followed correctly.
Failure to Complete Mandatory In-Service Training
Penalty
Summary
The facility failed to ensure that Nurse Aide (NA) #1 and NA #10 completed the mandatory 12 hours of in-service education annually. NA #1 completed only 5.78 hours of online training and attended in-person training sessions on Personal Protective Equipment (PPE) and hand washing, as well as on Abuse, Neglect, and Exploitation, but the duration of these sessions was not specified. Additionally, NA #1 did not receive any dementia care training. NA #10 did not complete any online training but attended the same in-person training sessions as NA #1, also without specified durations, and similarly did not receive dementia care training. An interview with RN #5 revealed that she was responsible for providing the education and in-service training through an online portal and in-person sessions, but she could not explain why the mandatory training was not completed. The facility also failed to provide an annual in-service training policy when requested.
Failure to Use Urinary Privacy Bag
Penalty
Summary
The facility failed to ensure a urinary privacy bag was utilized for Resident #477, who had a suprapubic catheter. Resident #477, diagnosed with a fracture of the left femur, benign prostatic hyperplasia with lower urinary tract symptoms, and dementia, was observed in the dining area with a urinary collection bag attached to the wheelchair without a privacy cover. The Nursing Admission Assessment indicated that Resident #477 required extensive assistance for personal hygiene, bathing, toileting, dressing, and transfers, and had a suprapubic catheter in place. An interview with the Occupational Therapist (OT) who assisted Resident #477 out of bed revealed that she was unaware of the need for a privacy cover for the urinary collection bag. The Director of Nursing (DNS) confirmed that the facility's policy required all urinary collection bags to have a privacy covering and that staff, including the therapy department, were educated on this policy. However, the facility was unable to provide a written policy regarding the use of privacy covers for urinary collection bags.
Failure to Document and Update Advance Directives
Penalty
Summary
The facility failed to ensure that Resident #21's current preference for code status was accurately documented in both the paper and electronic health records. Despite having a Resident Healthcare Instruction form indicating a full code status, a transfer document from a recent hospitalization indicated a Do Not Resuscitate (DNR) status. Interviews with staff revealed confusion and lack of clarity regarding who was responsible for updating the code status in the Electronic Health Record (EHR), leading to discrepancies in the resident's documented preferences. The Director of Nursing Services (DNS) and the Administrator acknowledged the failure to update the advance directive upon the resident's return from the hospital, resulting in conflicting information in the resident's records. Resident #428's medical records also lacked documentation of an advance directive upon admission. Although a State of Connecticut transfer order indicated a DNR status, there was no evidence in the paper chart or EHR that the resident or their representative had been given the opportunity to choose an advance directive. An interview with an LPN confirmed the absence of documentation and the failure to complete the advance directive process upon admission. It was only after surveyor inquiry that a signed advance directive consent and a physician's order were obtained, confirming the resident's DNR status. Similarly, Resident #527's records did not include a physician order or identification of code status in either the paper chart or EHR. The paper chart contained a blank and unsigned Resident Healthcare Instruction form. Interviews with nursing staff revealed that the responsibility for completing an advance directive upon admission was unclear, and no advance directive was obtained for the resident during their stay. Subsequent to surveyor inquiry, efforts were made to contact the resident's representative to obtain the necessary documentation. The facility's policy requires that code status be easily accessible and documented as part of the admission order set, which was not adhered to in these cases.
Failure to Notify Resident Representative of Significant Weight Loss
Penalty
Summary
The facility failed to ensure that the representative of a resident with dementia, myocardial infarction, and hypertension was notified of a significant weight loss. The resident, who was severely cognitively impaired and required assistance with eating, experienced a weight loss from 139.1 lbs to 133.7 lbs between July 1, 2023, and August 1, 2023, which was a 7.6% weight loss. Despite a physician's order to weigh the resident monthly and a care plan that included monitoring for unplanned weight loss, the resident's representative was not informed of this significant change. Further review showed that the resident's weight continued to decline, reaching 127.1 lbs by October 2, 2023, marking an 8.6% weight loss over three months. The dietician confirmed the significant weight loss trend but admitted that the facility lacked a specific policy for notifying family or representatives of such changes. The dietician also noted that no single person was responsible for making these notifications, indicating a systemic issue in communication and responsibility within the facility's team.
Failure to Ensure Resident's Right to be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure Resident #527's right to be free from physical restraints. Resident #527, who had diagnoses including Down Syndrome, Alzheimer's Disease, and diabetes mellitus, was admitted with psychiatric and behavioral issues. The resident exhibited behaviors such as agitation, restlessness, and attempts to self-transfer, which placed them at risk for falls. Despite these behaviors, the facility's care plan and interventions did not adequately address the resident's needs, leading to an incident where the resident was found restrained to their wheelchair with a bed sheet tied around their waist by a nursing assistant (NA) due to insufficient staffing and inability to provide one-to-one supervision. On the day of the incident, the facility was short-staffed, with only one NA present initially, and additional NAs arriving later in the shift. The NA who restrained Resident #527 reported feeling overwhelmed by the resident's behaviors and the demands of other residents, leading her to use the restraint as a temporary measure to prevent the resident from falling or causing harm. The restraint was discovered by a Speech Language Pathologist (SLP), who removed it and reported the incident to the charge nurse and her supervisor. However, there was a delay in reporting the incident to higher management, and conflicting accounts from staff about who was informed and when. Interviews with facility staff, including the Director of Nursing Services (DNS) and the Administrator, revealed ongoing issues with staffing shortages and inadequate supervision for residents with high behavioral needs. The DNS and Administrator acknowledged the challenges in providing appropriate care for Resident #527 and the lack of specific interventions in the care plan to manage the resident's behaviors. The facility's policy prohibited the use of physical restraints not required to treat medical symptoms, highlighting a significant deficiency in ensuring resident safety and compliance with regulatory standards.
Failure to Timely Report Allegation of Mistreatment
Penalty
Summary
The facility failed to report an allegation of mistreatment involving Resident #527 to the state agency in a timely manner. Resident #527, who had diagnoses including Down Syndrome, Alzheimer's Disease, and diabetes mellitus, was admitted with psychiatric and behavioral issues. The resident required extensive assistance for mobility and toileting and had a care plan addressing behavioral problems and fall risks. On a specific date, the resident was found restrained to a wheelchair with a bed sheet tied around the waist, an act admitted by NA #12. However, the incident was not reported to the RN Supervisor or managerial staff until three days later, and the Administrator delayed reporting to the state agency until the following day, citing a lack of information from a witness as the reason for the delay. The facility's policy on Abuse, Neglect, and Exploitation mandates immediate reporting of suspected abuse to a supervisor and subsequent reporting to the Administrator or designee within two hours. Despite this policy, the Administrator acknowledged awareness of the two-hour reporting window but failed to comply. The delay in reporting the incident to the state agency constitutes a deficiency in adhering to the facility's abuse reporting protocols.
Failure to Update Care Plans and Implement Interventions
Penalty
Summary
The facility failed to update and implement new interventions in the care plans for several residents following significant events. Resident #6, who had diagnoses including muscle weakness, Alzheimer's disease, and seizures, experienced two falls on 10/14/23 and 10/31/23. Despite these incidents, the care plan was not updated with new interventions to prevent future falls, and the existing intervention of using a floor mat was not consistently implemented. Additionally, the facility's policy of closely monitoring residents after a fall was not followed, as evidenced by the unwitnessed fall in the dining room on 10/31/23. Resident #9, with diagnoses including pneumonia, urinary tract infection, dementia, and bipolar disorder, developed an unstageable pressure ulcer on the left heel. The care plan, which initially did not include a turning or repositioning schedule, was not updated to reflect the resident's increased need for assistance following a decline in condition. Despite the worsening of the pressure ulcer, no new interventions were added to the care plan to prevent further deterioration. Resident #68, admitted with Alzheimer's dementia and an infection of the right hip prosthesis, experienced an unwitnessed fall on 10/27/23. The care plan was not revised to include additional interventions to prevent future falls, even though a physical therapy evaluation identified multiple fall risk factors. Similarly, Resident #527, with diagnoses including Down Syndrome, Alzheimer's Disease, and diabetes mellitus, exhibited behaviors that increased the risk of falls and injury. The care plan did not provide specific interventions for staff to implement when the resident exhibited these behaviors, leading to an incident where the resident was improperly restrained with a bed sheet for safety reasons.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for Resident #23, who was admitted with diagnoses including chronic kidney disease, total hip arthroplasty, and gout. The resident was cognitively intact and required extensive assistance with bed mobility, toilet use, and personal hygiene. Despite a physician's order dated 8/25/23 to consult podiatry as needed, no referral to podiatry was noted in the medical record. On 9/7/23, a physician's progress note identified that Resident #23's right great toe was swollen, yet no podiatry consult was made. Observations on 11/7/23 revealed that Resident #23's toenails were long and curling forward, and Person #2 confirmed having requested foot care for the resident multiple times without any action taken. Interviews and clinical record reviews indicated that any staff member could have brought concerns about the resident's toenails to the nurse, who would then request a podiatry consult. However, RN #1 was unable to locate any record of concerns being raised by the family or staff regarding the resident's toenails. The facility's Foot Care policy, dated 8/7/23, directed that residents with complicating disease processes requiring foot care must be referred to qualified professionals such as podiatrists. This policy was not followed, resulting in the deficiency noted in the report.
Failure to Implement Fall Prevention Measures and Conduct Risk Assessments
Penalty
Summary
The facility failed to ensure care plan interventions were implemented, provide adequate supervision to prevent falls, and conduct risk assessments following falls for three residents. Resident #6, diagnosed with muscle weakness, Alzheimer's disease, and seizures, was identified as a fall risk. Despite care plan interventions such as the use of floor mats and encouraging the use of a call bell, Resident #6 experienced two falls. Observations revealed that the resident's bed was in a high position without floor mats, contrary to the care plan. Interviews with staff indicated inadequate monitoring and insufficient staffing during the incidents, leading to unwitnessed falls and non-compliance with the fall protocol. Resident #68, admitted with Alzheimer's dementia and an infection of the right hip prosthesis, was initially assessed as a low fall risk. However, after an unwitnessed fall, it was found that quarterly fall risk assessments had not been completed since admission, and no fall risk assessment was conducted post-fall. The Director of Nursing confirmed the lapse in protocol, and the Physical Therapist classified the resident as a high fall risk based on a subsequent evaluation. Resident #527, with diagnoses including Alzheimer's disease, bacterial pneumonia, and Type 2 Diabetes, was identified as a high fall risk upon admission. Despite this, after a witnessed fall, the facility failed to complete a fall risk assessment post-fall. Instead, the facility's process involved a Nursing Change of Condition Evaluation and a verbal referral to Physical Therapy, which did not align with the facility's fall management policy. The Director of Nursing acknowledged the failure to follow the policy, which required reassessments after falls to minimize recurrence and risk.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide timely notification to the Ombudsman regarding multiple transfers of a resident to the hospital. Resident #21, who had diagnoses including heart failure, anemia, and dementia, experienced several medical emergencies that required hospital transfers. These incidents included elevated temperature, falls with head injuries, dislodged cholecystectomy drain, abnormal vital signs, and other acute conditions. Despite these transfers, the facility did not notify the Ombudsman as required by their policy and federal regulations. Interviews with the Social Worker and the Ombudsman revealed that the facility's process for notifying the Ombudsman was inadequate. The Social Worker indicated that notifications were made using an online reporting system every 30 days, but documentation of these reports was not provided. The Ombudsman confirmed that Resident #21's transfers were not reported, and only three months of reporting appeared in the system from 2021 to the present. The facility's Discharge and Transfer Policy required verbal and written notifications to the resident and their representative, as well as copies of notices to the Ombudsman, which were not adhered to in this case.
Failure to Notify Resident Representative of Bed Hold Policy
Penalty
Summary
The facility failed to provide the required notification of the bed hold policy for a resident with diagnoses including heart failure, anemia, and dementia. The resident was moderately cognitively impaired and required supervision and assistance for daily activities. Despite multiple hospital transfers and returns, the facility did not consistently notify the resident's representative in writing about the bed hold policy as required. Specifically, notifications were missing for hospital admissions on several dates, including 9/25/22, 12/1/22, 12/24/22, 1/29/23, 2/12/23, 7/29/23, and 8/14/23. The Business Office Manager (BOM) acknowledged the oversight and indicated that the responsibility for completing the Bed Hold Notice of Policy & Authorization form had recently shifted from the Admissions department to the Business Office. The facility's policy mandates that the resident or their representative be notified in writing about the bed hold policy upon each transfer, with the notice delivered via email, fax, or mail within 24 hours if the representative is not present. However, this procedure was not followed for the specified hospital admissions, resulting in a failure to comply with the notification requirements.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 528 citations issued within 25 miles in the last 12 months — including the 8 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Apple Rehab Guilford | 0.5 mi | ★★★★★ | 2 | 0 |
| Guilford House, The | 4.8 mi | ★★★★★ | 2 | 0 |
| Evergreen Woods | 6.2 mi | ★★★★★ | 5 | 0 |
| Ark Healthcare & Rehabilitation At Branford Hills | 10.9 mi | ★★★★★ | 24 | 0 |
| Aaron Manor Nursing & Rehabilitation | 11.5 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.