Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Alden Meadow Park Hcc during CMS and state inspections, most recent first.
The facility failed to maintain an effective infection prevention and control system for staff illness tracking and return-to-work decisions. Staff call-ins included headache, sore throat, cough/cold, stomach issues, and being sick, but the line list mainly documented fever and did not consistently capture symptoms needed to determine exclusion timing. The ADON/IP stated the facility mainly followed ARI protocol when fever was present, while the DON stated staff symptoms should be documented so the IP can determine how long they must remain off work and that staff with COVID symptoms should have testing before returning.
Failure to complete required employee background checks. The facility did not follow its screening policies for abuse prevention when it failed to complete the required WI Caregiver Background Check for a social service director and a receptionist, and did not obtain an IL or national background check for a contracted PT who had lived outside WI within the past 3 years. Interviews showed the BOM treated clinical and non-clinical staff differently, while the NHA stated all staff should have the caregiver background check completed and out-of-state residents should have the appropriate state-specific or national check.
Failure to Report Abuse Allegation: A cognitively intact resident reported that a CNA was rough during bed turning and caused pain by using his hands instead of a draw sheet. The concern was shared with the NHA and DON and documented as a grievance, but staff did not treat it as an abuse allegation or report it to the state agency as required by policy. Multiple staff members knew the resident believed the CNA had been rough with her, and the DON did not view the concern as major.
Failure to Thoroughly Investigate Allegation of Abuse: A cognitively intact resident reported that a CNA was rough and hurt her during cares, and staff documented that she did not want that CNA to provide care. Interviews showed the resident described painful handling during turning, while another CNA said the resident had told her the CNA was rough and that rough or aggressive care would be abuse. The DON and NHA did not complete a full investigation, and no other residents or staff were interviewed to determine whether additional abuse had occurred.
A resident with multiple complex medical conditions experienced increased pain, swelling, and bruising in her leg after returning from a dental appointment. Facility staff did not complete a timely RN assessment or provide ongoing monitoring and documentation of the resident's symptoms, despite clear evidence of a change in condition. Pain assessments were inconsistent with hospice documentation, and critical information was not communicated to providers or included in the medical record. These failures resulted in a deficiency related to inadequate assessment and monitoring of a resident's change in condition.
A resident with multiple chronic conditions developed swelling, bruising, and pain in the lower extremity after returning from a dental appointment, with no clear cause identified. Staff noted the injury but did not complete or document an incident report, and the injury was not reported to the State Agency as required by facility policy. Interviews revealed confusion among staff regarding documentation and reporting responsibilities, and the DON later confirmed the injury was of unknown source and had not been reported.
A resident with multiple chronic conditions developed pain, swelling, and bruising to the leg after a dental appointment, later found to have a possible fracture. Despite facility policy requiring investigation of injuries of unknown origin, staff did not complete an incident report or conduct a thorough investigation, and documentation was inconsistent. The DON and administrator confirmed that the injury was not investigated as required.
A resident with multiple chronic conditions experienced increased pain, bruising, and swelling after an off-site dental appointment, but facility staff failed to accurately document her pain, the injury event, and follow-up assessments in her medical record. Facility pain assessments did not match hospice nurse notes, and key documentation such as hospice progress notes and provider summaries were missing. Staff interviews confirmed incomplete documentation and lack of adherence to expected record-keeping practices.
The facility failed to accurately report staffing information to CMS, affecting all 65 residents. The Payroll Based Journal (PBJ) reporting was inaccurate, triggering concerns for low weekend staffing, lack of 24-hour licensed nursing coverage, and insufficient RN hours. The Nursing Home Administrator indicated that data entry errors by the Corporate Office staff led to the facility's star rating dropping to 1 out of 5.
A facility failed to accurately document a resident's advance directive in their EHR. Despite having a signed DNR order, the EHR incorrectly indicated a Full Code status. Staff members, including an LPN and RNs, confirmed they would follow the Full Code status as shown in the EHR. The discrepancy was discovered during a survey, revealing a failure in the facility's process to ensure consistent documentation of the resident's end-of-life care preferences.
A resident's room was found with breakfast and lunch trays containing dirty dishes and old food hours after meals, compromising the homelike environment. Despite being cognitively intact and able to feed herself, the resident expressed dissatisfaction with the situation. Facility staff, including CNAs and an LPN, failed to notice the trays during their visits, and the ADON acknowledged the oversight, stating it was not acceptable for trays to remain for such an extended period.
A resident with arthritis and mobility issues was not repositioned every two hours as required by their care plan, leading to prolonged periods of discomfort. Observations showed the resident remained in the same position for hours without staff assistance, despite the facility's policy and care plan directives.
A resident with limited mobility and significant pain was not walked according to her care plan in a LTC facility. Despite her willingness and the potential pain relief from walking, staff frequently did not assist her due to time constraints and staffing issues. Documentation showed numerous instances where walking was not recorded or marked as not applicable, indicating non-compliance with the care plan.
A resident with rheumatoid arthritis and other chronic conditions experienced inadequate pain management at an LTC facility. Despite reporting severe pain, staff failed to assess and document her pain levels accurately, and non-pharmacological interventions were not consistently provided. Interviews revealed communication issues and a lack of proactive pain management strategies, leading to the resident feeling ignored and untreated.
The facility failed to report an abuse allegation within the required timeframe. An incident occurred where a resident alleged another resident attempted to trip them. The report was submitted six hours late, and the investigation results were also delayed. Both residents had cognitive impairments and behavioral issues documented in their care plans.
A facility failed to ensure proper hand hygiene during wound care for a resident with multiple chronic wounds. The RN did not change gloves or perform hand hygiene between treating different wound sites, contrary to the facility's guidelines. The resident had a history of diabetes and other conditions, requiring daily dressing changes. Interviews confirmed the RN was trained to prevent cross-contamination but did not adhere to the protocol during the observed care.
A resident with complex medical needs was discharged from a facility due to nonpayment, despite pending Medicaid eligibility. The facility failed to ensure a safe and sustainable discharge plan, resulting in the resident missing chemotherapy treatments and lacking access to medications. The facility did not notify the Ombudsman prior to the involuntary discharge, violating policy requirements.
Infection Control: Incomplete Staff Symptom Tracking and Return-to-Work Monitoring
Penalty
Summary
The facility failed to ensure an effective infection prevention and control system for staff with acute respiratory illness and other symptoms. From February through April 2026, there were 33 staff call-ins for symptoms including sore throat, headache, cough/cold, stomach issues, and being sick, but the staff line list only consistently documented fever and did not consistently capture the symptoms needed to determine exclusion or return-to-work timing. The facility policy stated staff with mild to moderate ARI could return to work only after specific criteria were met, including at least 3 days since symptom onset, 24 hours fever-free, improved symptoms, and feeling well enough to return. During interview, the ADON/IP stated that when the line list says sick it may mean non-respiratory symptoms such as headache and that the facility mainly follows ARI protocol if a fever is present. The ADON/IP also stated some staff had COVID testing before returning to work and that she was trying to improve symptom screening and the line listing. The DON stated staff should have symptoms listed so the IP can determine how long they need to be off work and that staff with COVID symptoms should have a COVID test before returning to work. The staff line list showed inconsistent time off, ranging from 1 to 7 days from call-in to return to work.
Failure to Complete Required Employee Background Checks
Penalty
Summary
The facility failed to implement written policies and procedures for screening employees to prevent abuse, neglect, and theft, affecting 3 of 8 background checks reviewed. The facility’s Abuse Prevention and Reporting policy dated 11/25 stated that pre-employment screening required a Wisconsin DOJ background check and, if an applicant currently resided in Illinois or had lived outside Wisconsin within the past 3 years, the appropriate state police healthcare worker background check or other applicable state check. The Criminal Background Investigations Wisconsin Facilities policy dated 1/25 also stated that no individual should be permitted to work in a capacity that provides care or services to residents without appropriate background screening and clearance. PT J, a contracted physical therapist hired on 6/7/25, indicated on the Background Information Disclosure that she did or did live outside Wisconsin within the last 3 years, but no Illinois or national background check was completed for her. SSD K, hired on 1/3/26, did not have the Wisconsin Caregiver Background Check completed and therefore did not have Government Findings Report results. Receptionist L, hired on 2/26/26, also did not have the Wisconsin Caregiver Background Check completed and did not have Government Findings Report results. During interviews, the Business Office Manager stated she ran caregiver background checks for clinical staff and general checks for non-clinical staff, and said PT J’s contracted company did not do an Illinois check because PT J was not working in an Illinois facility. The Nursing Home Administrator stated all staff should have the caregiver background check completed and that staff who had resided outside Wisconsin should have that state-specific or a national background check completed.
Failure to Report Abuse Allegation
Penalty
Summary
The facility did not ensure that an allegation of abuse was reported immediately, and no later than 2 hours after the allegation was made, to the appropriate state agency. R7, a cognitively intact resident with a BIMS score of 15 out of 15 and partial/moderate assistance needs for rolling left to right, reported that CNA D hurt her while turning her in bed. R7 stated that the aide did not use the draw sheet and instead used his hands in a way that felt like fists pushing into her hips, causing significant pain. R7’s concern was documented as a grievance, and the information was shared with facility leadership, including the NHA and DON, but it was not treated as an abuse allegation for reporting purposes. R7 told staff that she no longer wanted CNA D to provide her care because he had been rough with her. CNA F stated that R7 told her CNA D had been rough during care and that she considered rough or aggressive care to be abuse. CNA D also acknowledged that R7 said he hurt her when turning her and that he told colleagues he would not be able to care for her. During interviews, the NHA stated that no one had reported to her that CNA D was rough with or hurt R7, and the DON stated that she did not feel the concern rose to the level of anything major. The facility’s abuse policy required immediate reporting of any allegation or reasonable suspicion of abuse, and required the Wisconsin DQA to receive the initial allegation report immediately. The survey found that the facility considered the matter a grievance instead of an abuse allegation, despite multiple staff members knowing that R7 believed CNA D had been rough with her, and therefore did not report the accusation to the state reporting agencies.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility did not ensure that an allegation of abuse involving a CNA and a resident was thoroughly investigated after it became aware of the concern. The resident involved, R7, was admitted to the facility and had a most recent MDS showing a BIMS score of 15 out of 15, indicating she was cognitively intact. Her MDS also showed she required partial/moderate assistance for rolling left to right. On 4/6/26, the facility received a grievance/concern stating that R7 requested CNA D not do her cares anymore. The grievance was documented by the Activities Director and forwarded to the Nursing Home Administrator, who noted that CNA D would no longer provide cares for R7 and that both were aware of the preference. During later interviews, R7 stated that when CNA D was putting her on her side, he hurt her and used his fists or palms on her hip area. R7 also stated she had arthritis in both hips and that other aides used a draw sheet when rolling her to avoid causing pain. Additional interviews showed that CNA F had heard R7 say CNA D was rough with her, and CNA F stated she would consider rough or aggressive care to be abuse. CNA D stated that R7 refused his service because he hurt her when turning her, and he had told colleagues and the Scheduling Coordinator that he could not care for her. The Scheduling Coordinator believed the issue was that R7 did not want male caregivers or did not want CNA D because they were close in age. The DON stated R7 said CNA D was a little rough and moved her too quickly, but she did not feel the concern rose to anything major. The facility did not interview other residents or staff to determine whether additional abuse by CNA D had occurred, and therefore did not complete a thorough investigation as required by policy.
Failure to Assess and Monitor Change in Condition Following Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide care and treatment in accordance with professional standards of practice, specifically related to the assessment and monitoring of a resident's change in condition. The resident, who had multiple complex medical diagnoses including diabetes with neurological complications, chronic kidney disease, fibromyalgia, epilepsy, osteoporosis, and Parkinson's disease, experienced an increase in pain and swelling in her leg/foot after returning from a dental appointment. Despite the resident's report of pain and visible symptoms such as swelling and bruising, the facility did not complete a timely RN assessment, nor did staff continuously assess, record, or monitor the resident's change in condition for new or worsening symptoms as required by facility policy and the Wisconsin Nurse Practice Act. Documentation revealed inconsistencies and omissions in the resident's medical record. Pain assessments recorded by facility staff often indicated no pain, even when hospice notes documented severe pain (up to 9 out of 10). The facility administered as-needed pain medication despite documenting pain scores of zero. There was no evidence of ongoing monitoring of the resident's edema, range of motion, or bruising following the initial report of injury. Additionally, the facility failed to document an incident report for the injury, did not provide hospice nurse progress notes as part of the medical record, and did not communicate critical changes in the resident's condition to the appropriate providers in a timely manner. Interviews with facility staff, hospice staff, and the resident's representative highlighted further lapses. Staff were unclear about the circumstances of the injury, and there was no documentation of a safety or positioning assessment prior to transporting the resident to the dental appointment. The resident's decline, subsequent x-ray findings of a questionable non-displaced tibial fracture, and eventual death were not adequately assessed or monitored by facility nursing staff. The lack of systematic and continual assessment, documentation, and communication regarding the resident's change in condition directly contributed to the deficiency cited by surveyors.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, and injuries of unknown source were reported immediately to the State Agency, as required by both regulation and facility policy. A resident with multiple diagnoses, including Parkinson's disease, dementia, and a history of falls, sustained an injury of unknown source on two occasions. On the first occasion, the resident returned from a dental appointment and began complaining of pain in the right lower extremity, with staff and hospice nurses noting swelling, bruising, and pain. Despite these findings, there was no clear documentation of an incident report or a nurse progress note detailing the injury, and staff were uncertain about the cause of the injury. Interviews with various staff members, including the Business Office Manager, LPNs, and the Assistant Director of Nursing, revealed inconsistent accounts regarding the incident. The staff transporting the resident and the dental office staff did not recall any incident during the outing. Nursing staff noted the resident's complaints and physical findings but did not complete or document an incident report, and there was confusion about who was responsible for documentation and assessment. The Director of Nursing later confirmed that the injuries were of unknown source and acknowledged that they were not reported as required. The facility's own policy mandates immediate reporting of injuries of unknown origin to the State Agency, including an initial allegation report and a five-day final investigation report. Despite being aware of the resident's injuries and the lack of a clear cause, the facility did not fulfill these reporting obligations. The Nursing Home Administrator confirmed that the injuries should have been reported but were not, resulting in a deficiency for failure to report suspected abuse, neglect, or injuries of unknown source.
Failure to Investigate Injuries of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown source for a resident with multiple complex medical conditions, including Parkinson's disease, dementia, fibromyalgia, and a history of falls. On two separate occasions, the resident sustained injuries—first noted as pain and bruising to the right lower extremity after returning from a dental appointment, and later identified as a questionable non-displaced fracture on X-ray. Despite the facility's policy requiring immediate reporting, assessment, and investigation of such injuries, there was no documented incident report or comprehensive investigation initiated by staff. Multiple staff members, including LPNs, the Assistant DON, and the DON, were aware of the resident's complaints of pain, swelling, and bruising. However, there was confusion and lack of clarity regarding the cause of the injury, with some staff assuming the injury occurred during transportation to the dentist, while others noted the resident was non-ambulatory and could not have walked as described. Documentation was inconsistent, with some staff believing others would complete necessary notes or assessments, and no clear record of a thorough assessment or investigation being completed. Interviews with staff and review of records revealed that the facility did not follow its own abuse prevention and reporting policy, which mandates investigation of all injuries of unknown origin to rule out abuse or neglect. The DON and Nursing Home Administrator both acknowledged that the injuries were of unknown source and should have been investigated, but confirmed that no such investigation took place. This lack of action resulted in a failure to ensure the resident's safety and compliance with regulatory requirements.
Failure to Maintain Complete and Accurate Medical Records for Resident with Change in Condition
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for a resident who experienced a significant change in condition. The resident, who had multiple complex diagnoses including Type 2 Diabetes Mellitus with neurological complications, chronic kidney disease, fibromyalgia, epilepsy, osteoporosis, and Parkinson's disease, experienced increased pain, bruising, and swelling in her lower left extremity following an off-premises dental appointment. Staff interviews and record reviews revealed that the resident's pain was not accurately documented in the medical record, with facility pain assessments consistently recorded as 0 out of 10, despite hospice nurse notes indicating pain levels as high as 10 out of 10. Additionally, the administration of as-needed pain medication was not supported by corresponding pain assessments in the medical record. The medical record lacked critical documentation, including a description of the injury, details of the event that led to the change in condition, hospice nurse progress notes, and after-visit summaries from the dental provider. Staff failed to capture the resident's account of the incident and did not document ongoing monitoring or assessments following the change in condition. Interviews with facility staff, including the DON, ADON, and LPNs, confirmed that documentation was incomplete or missing, and that expected practices such as documenting assessments, pain ratings, and communication with hospice or medical providers were not followed. The facility also did not provide a policy related to charting, documentation, or medical record filing when requested. The deficiency was further evidenced by discrepancies between hospice and facility documentation, with hospice records reflecting significant pain and changes in condition that were not mirrored in the facility's records. The facility's failure to maintain accurate and complete medical records was acknowledged by both the DON and the Nursing Home Administrator, who confirmed that the resident's medical record was not complete and that documentation practices did not meet expectations. The absence of hospice notes and other essential documentation in the resident's chart was also confirmed during the survey.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to ensure accurate reporting of mandatory staffing information to the Centers for Medicare & Medicaid Services (CMS) based on payroll data. This deficiency affected all 65 residents residing within the facility. The facility's Payroll Based Journal (PBJ) reporting was inaccurate, triggering concerns for four fiscal year quarters due to excessively low weekend staffing, one quarter for failure to have licensed nursing coverage 24 hours a day, and one quarter for failure to have registered nurse (RN) hours each day. The issues were evidenced by the facility's inability to provide surveyors with copies of the CASPER Report 1702D, which would have shown the hours reported to CMS. The facility's PBJ Staffing Data Reports for various fiscal quarters identified areas of concern, including excessively low weekend staffing and a one-star staffing rating. The facility also failed to maintain licensed nursing coverage 24 hours a day for several days within the quarter, as indicated by the infraction dates listed in the report. The Nursing Home Administrator (NHA) indicated that the Corporate Office staff were responsible for submitting the PBJ data to CMS. However, due to a failure in the data entry process, only partial data was submitted, resulting in the facility's star rating dropping to a 1 out of 5. The NHA explained that the data entry error occurred because the Corporate Office staff did not save the data correctly before submission, leading to inaccurate reporting of staffing information.
Inaccurate Documentation of Advance Directive in EHR
Penalty
Summary
The facility failed to ensure that a resident's advance directive was accurately reflected in their medical record. The resident, identified as R312, had a signed Do Not Resuscitate (DNR) order, but the electronic health record (EHR) incorrectly indicated a Full Code status, which means all life-saving measures would be taken in the event of cardiac or respiratory arrest. This discrepancy was discovered during a survey when the surveyor observed the EHR banner and interviewed several staff members, including LPN C, RN D, and RN E, all of whom confirmed they would follow the Full Code status as indicated in the EHR. R312 was admitted to the facility with chronic conditions including Chronic Kidney Disease, Type 2 Diabetes Mellitus, and Congestive Heart Failure. The resident's cognitive status was assessed as moderately impaired. Despite having a signed DNR form scanned into the EHR, the facility's system still displayed a Full Code status, leading to potential confusion among staff regarding the resident's end-of-life care preferences. Interviews with the Director of Nursing (DON B) and the Director of Social Services (DSS F) revealed that the facility's policy required all advance directive preferences to be documented and updated in the resident's care plan. However, the inconsistency between the signed DNR form and the EHR banner was not addressed until the surveyor's intervention. This oversight highlights a failure in the facility's process to ensure that a resident's advance directive wishes are accurately and consistently documented across all relevant records.
Failure to Maintain a Homelike Environment for Resident
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, identified as R33, as evidenced by the presence of breakfast and lunch trays with dirty dishes and old food left in the resident's room for hours after meals. R33, who was admitted with diagnoses including the need for assistance with personal care and mobility issues, was observed asleep in her wheelchair with the trays still present. Despite being cognitively intact and able to feed herself independently, R33 expressed dissatisfaction with the situation, stating it upset her and would be embarrassing if visitors came. Interviews with facility staff, including CNAs and an LPN, revealed that they had not noticed the trays during their visits to R33's room, and they agreed that the presence of dirty dishes did not constitute a homelike environment. The Assistant Director of Nursing acknowledged that while R33 sometimes requests her meal trays to remain longer, it was not acceptable for a breakfast tray to still be present after 2:00 PM. The deficiency highlights a lapse in maintaining an orderly and sanitary environment as required by the State of Operations Manual Appendix PP.
Failure to Reposition Resident as Per Care Plan
Penalty
Summary
The facility failed to provide necessary repositioning assistance for a resident, identified as R33, who was dependent on staff for activities of daily living (ADLs) due to multiple medical conditions, including rheumatoid arthritis and osteoarthritis. Despite the care plan indicating the need for repositioning every two hours to prevent discomfort and potential skin integrity issues, documentation showed inconsistent repositioning, with no evidence of repositioning every two hours as required. Observations by the surveyor on January 30, 2025, revealed that R33 remained in the same position in her wheelchair for several hours without staff intervention, despite expressing pain from prolonged sitting. Interviews with staff, including CNAs and the Assistant Director of Nursing (ADON), highlighted discrepancies in understanding and executing the care plan for R33. While some staff believed R33 could reposition herself, others acknowledged her need for assistance due to her medical conditions. The ADON confirmed that staff were expected to assist with repositioning every two hours, which was not observed during the surveyor's visit. This lack of adherence to the care plan and facility policy resulted in the deficiency noted in the report.
Failure to Assist Resident with Mobility Needs
Penalty
Summary
The facility failed to ensure that a resident with limited mobility, identified as R33, received appropriate services and assistance to maintain or improve mobility. R33, who was admitted with multiple diagnoses including rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis, was not walked in accordance with her care plan. The care plan specified that R33 should ambulate with a gait belt and walker with assistance from staff daily, but documentation revealed numerous instances where this did not occur. Specifically, there were multiple shifts where walking was either not documented or marked as not applicable, indicating a lack of adherence to the care plan. Interviews with staff and the resident revealed that R33 experienced significant pain, which she believed could be alleviated by walking. Despite this, staff frequently did not assist her with walking due to time constraints and staffing issues. R33 expressed that she never refused to walk and desired to do so, but staff did not have the time to assist her. The facility's failure to provide the necessary assistance for walking was corroborated by interviews with CNAs and the Assistant Director of Nursing, who acknowledged the lack of adherence to the restorative walking program. The deficiency was further highlighted by the facility's documentation practices. The use of 'N/A' in charting was explained by staff as an indication that they did not have time to assist the resident with walking, rather than a refusal by the resident. Additionally, blank entries in the documentation suggested either a failure to perform the task or a failure to document it. The Assistant Director of Nursing admitted that the restorative program was new and that staff needed education on proper charting, but confirmed that the expectation was for staff to follow the care plan and physician orders for walking R33.
Inadequate Pain Management for Resident with Chronic Conditions
Penalty
Summary
The facility failed to adequately assess and manage the pain of a resident, identified as R33, who has multiple diagnoses that indicate a high likelihood of experiencing pain, including rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis. Despite these conditions, the facility did not provide appropriate non-pharmacological interventions or adequately assess the resident's pain levels. The resident reported experiencing sharp pains in her feet and toes, and at times rated her pain as 10 out of 10, yet felt ignored by the staff who did not believe her reports of pain. Observations and interviews revealed that the staff did not consistently assess the resident's pain before administering medications, and there was a lack of documentation regarding the resident's pain levels. The resident's pain assessments were often recorded as 0 or 1, despite her verbal reports of severe pain. Additionally, the facility's staff, including CNAs and LPNs, were not proactive in addressing the resident's pain or implementing non-pharmacological interventions such as walking, which the resident indicated would help alleviate her pain. Interviews with staff and family members highlighted a lack of communication and understanding of the resident's pain management needs. The Director of Nursing acknowledged issues with the documentation process, noting that the Nurse Practitioner often copied and pasted notes without reviewing the resident's chart. The resident's family member expressed concerns that the facility staff dismissed the resident's pain due to her age and hearing impairment, further contributing to the inadequate pain management provided to the resident.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency within the required timeframe. The incident involved two residents, one of whom alleged that the other attempted to trip them in the hallway. The facility's policy mandates that such allegations be reported within two hours if they result in serious bodily injury, or within 24 hours if no bodily injury occurs. However, the report was submitted six hours after the incident, which did not comply with the policy. Additionally, the facility did not submit the results of the investigation within the required five working days. The incident occurred on November 14, 2024, but the investigation report was not submitted until November 22, 2024. The Administrator acknowledged the delay but could not provide a reason for the late submission. Both residents involved had a history of cognitive impairments and behavioral issues, which were documented in their care plans.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident, which was observed by surveyors. The facility's Clinical Practice Guidelines for Non-Sterile Dressing Change required staff to perform hand hygiene and change gloves at specific steps during the wound care process. However, during an observation, a registered nurse (RN) did not adhere to these guidelines. The RN performed hand hygiene and applied gloves initially but failed to change gloves and perform hand hygiene between cleaning and dressing multiple wounds on the resident's right leg and foot. The resident involved had a medical history that included type 2 diabetes, congestive heart failure, chronic kidney disease, and anemia. The resident had diabetic foot ulcers, surgical wounds, and other chronic wounds requiring daily dressing changes. During the observed wound care, the RN did not perform hand hygiene or change gloves between treating different wound sites, which could lead to cross-contamination between the wounds. Interviews with the RN and the Director of Nursing (DON) confirmed that the RN was trained to perform hand hygiene and change gloves between wounds to prevent cross-contamination. The DON stated that the nurse should have completed the care for one wound before moving to the next, and hand hygiene should have been performed each time gloves were removed. The facility's failure to follow proper infection control procedures during wound care was identified as a deficiency.
Inadequate Discharge Planning for Resident with Pending Medicaid
Penalty
Summary
The facility discharged a resident, referred to as R1, despite the resident's pending Medicaid eligibility, which was a violation of the facility's discharge policy. R1 was given a discharge notice due to nonpayment, even though R1 was actively applying for Medicaid. The facility's policy requires that a resident may not be involuntarily discharged unless an alternate living arrangement has accepted the resident, and the alternate placement is arranged. However, R1 was discharged to a motel without a confirmed alternate living arrangement. R1 had a complex medical history, including lung cancer, congestive heart failure, acute kidney failure, alcoholic cirrhosis of the liver, depression, and anemia. At the time of discharge, R1 was undergoing chemotherapy and was cognitively intact. The facility's discharge planning policy was not adequately followed, as R1 was discharged without a sustainable plan for continued care, including access to necessary medications and transportation for medical appointments. R1 missed a chemotherapy treatment due to lack of transportation, and there was no evidence that the facility coordinated with other agencies to ensure R1's safe transition. The facility failed to notify the Ombudsman prior to R1's discharge, which is a requirement in cases of involuntary discharge. The facility's staff, including the Social Services Director and Nursing Home Administrator, attempted to discuss payment plans and discharge options with R1, but R1 refused to cooperate. Despite this, the facility did not ensure a safe and sustainable discharge plan, as R1 was left without adequate resources to manage his health needs post-discharge. The facility's actions resulted in R1 being discharged to a motel without proper support, leading to missed medical treatments and inadequate access to medications.
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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.
Illustrative
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Nursing homes near Clinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beloit Health And Rehabilitation Center | 7.4 mi | ★★★★★ | 19 | 0 |
| Autumn Lake Healthcare At Beloit | 8 mi | ★★★★★ | 16 | 0 |
| Oak Park Place Of Janesville | 9.6 mi | ★★★★★ | 1 | 0 |
| Fair Oaks Rehab & Healthcare | 10.8 mi | ★★★★★ | 26 | 1 |
| St Elizabeth Nursing Home | 11.2 mi | ★★★★★ | 19 | 0 |
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