Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aria At Mitchell Manor during CMS and state inspections, most recent first.
Incomplete Refrigerator Temperature Logs: Food service safety standards were not followed because temperature logs for two kitchen refrigerators were not kept current. The walk-in refrigerator log had not been completed for the prior day, and the kitchen-area refrigerator log was missing two PM readings. The Lead Cook and Dietary Manager acknowledged the missed entries and stated the PM staff member had not completed the readings.
Inaccurate PBJ Staffing Submission: The facility did not accurately submit Quarter 2 PBJ staffing data to CMS. The CASPER report showed excessively low weekend staffing even though weekend schedules showed regular coverage with nurses, a med tech, and CNAs, and staff interviews indicated the facility did not work short and that coverage was usually available. The NHA stated administration staff were not present on weekends and surveyors noted those staff should be coded differently.
Outdated employee background screening records were found during file review, including BID, DOJ, and IBIS forms that were not updated within the required timeframe for an RN, a housekeeper, and a CNA. Another CNA’s BID form was undated, so completion within the required period could not be verified. The NHA acknowledged the records were outdated and stated that new forms had been requested.
A facility failed to monitor significant weight loss for residents with complex medical conditions and did not document actual fluid intake for a resident on a 2000 mL fluid restriction. One resident had repeated unaddressed weight losses over several months without reweights or timely notification to the physician or RD, another lost nearly 8% in a month after admission with poor intake and meal refusals, and a third resident’s fluid restriction was not tracked in actual intake despite staff observing water glasses in the room and acknowledging the intake was not tallied.
Insulin storage and labeling were not maintained for several residents. Surveyors found two insulin pens stored together in a medication cart drawer without a bag, two insulin bottles stored together in the bottom of the cart without a medication container, and an open bottle of insulin that was not dated. An LPN and the ADON/IP acknowledged that insulin bottles should be dated when opened and that residents’ insulin pens are typically kept in named bags.
A resident with dementia, cerebrovascular disease, and high Braden scores had a Stage 4 left hip pressure injury. The wound NP changed the treatment to a daily regimen with Iodosorb gel and wound cleanser, but the facility continued the prior M/W/F treatment with manuka honey and calcium alginate silver until discharge. The ADON/IP later stated she was not sure why the order was not changed and said, "I messed up."
A resident with Parkinson's Disease and dementia, and severe cognitive impairment per BIMS, was observed during lunch being fed by a CNA who stood the entire time instead of sitting beside the resident. The DON stated staff are expected to sit next to residents when assisting with meals, but could not explain why the CNA stood while feeding the resident.
Resident Exposed During Wound Care: A resident did not receive privacy during wound care when an LPN left the room door open after a dressing was dropped and another surveyor approached while the resident's buttock remained exposed to the hallway. The ADON later shut the door, and the DON stated that should not happen. The resident said they preferred the door shut so they were not exposed.
A resident with anxiety disorder had a PRN lorazepam order without an end date or documented rationale for extended use. Psych and NP notes documented ongoing anxiety, panic symptoms, and continued lorazepam use, while the DON stated pharmacy recommendations would include stop dates; however, the 90-day PRN duration and psychosocial comfort rationale were not reflected in the resident’s record or current orders.
A resident with Parkinson's disease, severe cognitive impairment, and extensive ADL assistance needs elected hospice, but the facility did not schedule or complete the required Significant Change MDS within the required timeframe. An MDS LPN stated the facility completes an SCSA when a resident starts hospice, but was not aware the resident had enrolled in hospice and the assessment had not been initiated when surveyors reviewed the record.
A resident with PTSD did not have a PTSD assessment or a person-centered care plan identifying trauma history, triggers, or interventions. The resident’s care plan and quarterly review addressed mood and behavior issues, but staff interviews showed CNA staff were not informed of PTSD triggers, and the SSD stated she had never completed a PTSD assessment. The psych provider described PTSD as a historical diagnosis and did not include it in the assessment/plan.
Medication Error Rate Exceeded 5 Percent: An LPN made four medication errors during one resident’s med pass, resulting in a 13.33% error rate. The errors included giving incorrect doses of Amantadine HCI and Valproic Acid, failing to administer an ordered multivitamin with iron, and initially giving Polyethylene Glycol 3350 by the wrong route instead of enterally as ordered.
An LPN did not perform hand hygiene at multiple points during medication preparation and administration for a resident receiving medications through a G-tube. The LPN cleaned the medication cart, continued preparing medications while wearing gloves, removed gloves without cleansing hands, entered the resident’s room, changed gloves again without hand hygiene, and administered medications before later cleansing hands at the medication cart. The DON stated that hand hygiene was expected between patients and after glove removal.
A resident due for Prevnar 20 had no documentation in the chart showing pneumococcal vaccine education was provided or that the resident accepted or refused the vaccine. The DON and ADON stated the usual process was to offer immunization education on admission and document the resident’s response, but they agreed the record lacked that information even though hospital paperwork showed the resident had declined the vaccine there.
A resident due for the COVID-19 vaccine did not have documentation showing that education on the vaccine’s benefits and potential side effects was provided or that the resident accepted or refused the vaccine. The DON and ADON stated that new residents are approached with immunization information and the education and response are documented, but the resident’s record lacked this information, even though hospital discharge paperwork showed the resident had declined the vaccine at the hospital.
A resident’s representative twice reported to the Director of Care Transitions that staff were frustrated with the resident’s frequent call light use, allegedly yelled at and called the resident names, and that a CNA, described as agitated and aggressive, roughly repositioned the resident in bed, which the representative believed resulted in left 7th and 8th rib fractures and subsequent hospital transfer. The facility’s grievance log contained no entries for these concerns, the Director of Care Transitions did not document or retain any record of the reports or forwarding them to the DON or Administrator, and the DON, although she discussed the rib fractures with the representative and reviewed the chart, did not treat the concerns as a grievance or allegation of abuse requiring investigation, contrary to the facility’s grievance policy.
A resident with multiple fractures, osteoporosis, and significant comorbidities experienced severe left rib pain while being repositioned by a CNA, was assessed by nursing, and was sent to the ER where imaging showed new anterior rib fractures in addition to old fractures. The facility’s policy required immediate (within 2 hours) reporting of any allegation of abuse or incident resulting in serious bodily injury, and reporting of other incidents within 24 hours, to regulatory agencies. The resident’s representative later reported that the CNA had been extremely agitated about the call light, allegedly grabbed the resident around the torso, and yanked her backward in bed, which the representative believed caused the fractures, and raised concerns about how this could occur when repositioning had been done previously without incident. The DON spoke with the CNA, who reported hearing a “crack” during repositioning, and with the representative, but the DON and Administrator concluded that, due to the resident’s history of fractures and comorbidities, there was no need to treat the event or the representative’s concerns as an allegation of abuse or neglect, and they did not report the incident to the State Survey Agency.
A resident with multiple fractures, osteoporosis, and significant comorbidities required 1-person assistance and scheduled repositioning in bed. During staff-assisted repositioning, the resident experienced severe left rib pain, and imaging later showed new anterior rib fractures in the context of multiple old fractures. The resident’s representative reported that a CNA had entered the room agitated about call light use and allegedly grabbed the resident around the torso and yanked her backward in bed, raising concerns of possible mistreatment. Despite a facility policy requiring comprehensive internal investigations of such incidents, the DON relied on the resident’s fragility and physician input to conclude no investigation was needed, interviewed only the involved CNA, and did not interview other staff or residents or otherwise conduct the minimum investigative steps outlined in the abuse prevention program.
Surveyors found that the facility did not maintain a clean and homelike environment on one floor, with dirty, stained carpets, persistent urine odor, debris and dead insects in light fixtures, and unclean fans in the dining area. The elevator area was also dirty and obstructed by food particles. Staff interviews revealed no established cleaning schedules or documentation for these areas, and cleaning was only performed when issues were noticed or reported.
The facility failed to maintain an effective infection control program, lacking a comprehensive water management plan and proper PPE usage for a resident on droplet precautions. The 2nd floor closed unit was poorly maintained, with no documentation of regular flushing or risk assessment. Staff did not consistently wear required PPE, such as masks and eye protection, for a resident with pneumonia, indicating significant lapses in infection control practices.
The facility failed to provide written transfer notices to five residents or their representatives when they were hospitalized due to changes in condition. Despite the facility's policy requiring written notification, evidence of such notices was lacking, and verbal communication was sometimes used without proper documentation. This deficiency was noted by surveyors, and the facility was unable to provide further documentation.
The facility did not ensure timely administration of pneumococcal and influenza vaccines to two residents. One resident did not receive the pneumococcal vaccine as requested, and another did not receive the influenza vaccine for the current season. The facility's policy requires offering these immunizations unless contraindicated or already given, but delays occurred due to the pharmacy's scheduling practices.
A resident did not receive medications as prescribed due to the facility's failure to have the correct doses available. The resident was given a lower dose of folic acid than ordered, and Disulfram was not administered because it was not available. Staff interviews confirmed these issues, highlighting a failure to adhere to the facility's medication policy.
The facility failed to prevent accident hazards and implement fall interventions, affecting all residents on a unit. Insulin and blood glucose medications were left unattended, violating policy. A resident with severe cognitive impairment did not have fall interventions consistently in place, such as a body pillow and soft touch call light, despite being at high risk for falls. Staff interviews confirmed non-compliance with care plans.
Incomplete Refrigerator Temperature Logs
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety because temperature logs for two kitchen refrigerators were not kept up to date. The facility policy required refrigerated food storage temperatures to be maintained at or below 41 degrees F and for temperatures to be recorded twice per day, with time, temperature, and initials entered for each cooler in the department. On 06/28/2026, the surveyor observed that the walk-in refrigerator temperature log had last been completed on 6/26/26 for the AM shift, and the Lead Cook-G stated the log had not been completed the previous day and that they were the person who should have completed it. The surveyor also observed the temperature log for the refrigerator in the kitchen cooking area and noted that the 26th and 27th PM readings were not completed; Lead Cook-G confirmed those two readings were not done. On 06/29/2026, the Dietary Manager-H stated they were aware the two refrigerators had temperature logs that were not completed to date and said they had already spoken with the staff member on the PM shift who missed those readings.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to CMS. The deficiency involved Quarter 2 Payroll Based Journal staffing and census data for January 1 through March 31, 2026, which was reported as not accurately submitted. The CMS PBJ Staffing Data Report, CASPER Report 1705D, for fiscal year 2026 showed excessively low weekend staffing for the quarter, even though the facility assessment listed an average of 6 licensed nurses and 13 nurse aides on duty each day. Surveyors reviewed weekend schedules from the quarter and noted licensed nurses and CNAs present on each shift for each unit, with schedules consistently showing five or six nurses, one medication technician, and 11 or 12 CNAs per 24 hours. During interviews, the CNA scheduler and NHA stated the facility did not work short and that the scheduler or NHA could cover open shifts, while the DON stated the assistant DON, nurse supervisor, or DON would work if needed. The NHA also stated there was no way to fix the low weekend staffing because administration staff were not present on weekends, and surveyors noted administration staff should be coded differently. Staff interviewed later stated staffing was good on weekends and that coverage was generally available.
Outdated employee background checks and incomplete BID documentation
Penalty
Summary
The facility did not implement its abuse prevention policy related to screening employees for a prior history of abuse, neglect, exploitation, or misappropriation of resident property. During record review for employees working on the third floor, Registered Nurse-M, Housekeeper-N, and Certified Nursing Assistant-I were found to have background check documents that were not updated within four years of employment at the facility. Certified Nursing Assistant-E’s Background Information Disclosure form was also not dated, so it could not be determined whether it had been completed within the required time frame. The facility policy stated that it would not knowingly employ individuals who had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law, or who had disciplinary action against their license for such findings. On review of personnel files, RN-M’s BID, DOJ, and IBIS forms were completed in 2021, while Housekeeper-N and CNA-I had BID, DOJ, and IBIS forms completed only after the surveyor requested the paperwork. CNA-E’s BID form lacked a completion date. The Nursing Home Administrator stated that the forms were outdated, that new forms had been requested, and that an audit of employee files was underway.
Failure to Monitor Significant Weight Loss and Fluid Restriction
Penalty
Summary
The facility did not ensure acceptable nutritional status was maintained for residents with significant weight loss, and it did not monitor fluid intake for a resident on a fluid restriction. The report identified deficiencies involving residents with diabetes, cancer, Parkinson’s disease, dysphagia, protein-calorie malnutrition, end-stage renal disease, and dialysis dependence. Facility policies required monthly weights, reweights for significant changes, notification of the physician and dietitian, and documentation of fluid intake for residents on fluid restrictions. For one resident with diabetes, cancer, major depressive disorder, cognitive impairment, and dependence for most activities of daily living, the record showed repeated significant weight losses over several months. The resident weighed 180.5 pounds, then 176.5 pounds, then 169.9 pounds, and later 155.1 pounds, including losses of 5.7 percent in one month and 9 percent in one month. No reweights were documented after the significant losses, and no documentation was found showing nursing notified the physician or RD of the weight changes at the time they occurred. The resident stated they were not hungry and did not know why the weight loss was occurring. Interviews with staff showed the RD generally reviewed weights independently and was not notified by nursing of the losses. For another resident admitted with Parkinson’s disease, diabetes, protein-calorie malnutrition, dysphagia, and GERD, the record showed a significant weight loss shortly after admission. The resident weighed 131.4 pounds on admission and later 121.0 pounds, a loss of 7.9 percent in one month. The RD documented poor intake and meal refusals, but no documentation was found that the physician or RD was notified of the significant weight loss. Staff interviews also showed the resident’s care card did not match the resident’s actual ability to eat, as one nurse stated the resident had to be fed because of shaking movements, while the care card listed the resident as independent with eating. For the resident with end-stage renal disease and dialysis dependence, the facility did not monitor actual daily fluid intake despite a physician-ordered 2000 mL fluid restriction. The care plan and orders included the restriction and monitoring, but the CNA Kardex did not include the fluid restriction, and the TAR only showed that the restriction was active, not how much fluid was actually consumed. Surveyors observed multiple water glasses in the resident’s room, and staff interviews showed CNA staff were not aware of the restriction until told by nursing. The LPN stated the amount actually consumed was not documented, and the DON stated that beyond the care plan and order, the resident’s actual fluid consumption was not monitored.
Insulin Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles for five residents’ insulin medications. The facility’s policy required medications and biologicals to be stored safely and securely, and stated that when the original seal of a manufacturer’s container or vial is broken, the container or vial must be dated with the date opened and expiration date. During observation of the 3rd floor medication cart, surveyors found a Lantus Solostar insulin pen for R34 and a NovoLog Mix 70/30 insulin pen for R2 together in the bottom drawer of a compartment-type container, but not in a bag or other medication container. In another compartment, a Lispro insulin bottle for R36 and a Humulin R insulin bottle for R44 were also stored together in the bottom of the medication cart and not in a medication container. Surveyors also observed a bottle of Lantus insulin for R5 in the bottom drawer that was open, used, and not dated. When asked, an LPN stated that insulin pens are usually kept in a bag, though some do not have one, and said insulin bottles should be dated when opened. The ADON/IP later confirmed that insulin bottles should be dated when opened and stated that each resident has a bag with their name, while being informed of the insulin pens and bottles that were not in a bag or container and the undated open insulin bottle.
Failure to Implement Ordered Wound Treatment
Penalty
Summary
The facility did not ensure that a resident with a pressure injury received the ordered treatment and services for the left lateral hip wound. R54 had diagnoses including adult failure to thrive, dementia, and cerebrovascular disease, and was assessed as high risk for pressure injury development with repeated Braden scores of 12. The resident’s left trochanter/hip wound was documented as unstageable on admission, later identified by the wound NP as a Stage 4 pressure injury after debridement, with ongoing weekly wound assessments showing gradual improvement in size and tissue composition. On 4/1/26, the wound NP changed the treatment plan for the left hip pressure injury to daily cleansing with wound cleanser, irrigation, Iodosorb gel, continued calcium alginate with silver, and continued foam border dressing, while discontinuing Leptospermum honey. However, the April TAR showed the facility continued to provide the prior treatment of cleansing with normal saline, applying manuka honey, packing with calcium alginate silver, and covering with border foam dressing on a Monday/Wednesday/Friday schedule through the resident’s discharge. During interview, the ADON/IP, who was also the wound nurse, reviewed the wound order and stated she was not sure why the treatment was not changed and said, "I messed up."
Failure to Provide Dignified Feeding Assistance
Penalty
Summary
The facility did not ensure that each resident was treated with dignity and respect for 1 resident, R39. R39 had diagnoses of Parkinson's Disease and Dementia, and the quarterly MDS dated 3/31/26 showed a BIMS score of 3, indicating severe cognitive impairment. R39 was assessed as requiring set up or clean up assistance. During the lunch meal observation on 6/28/26 in the 3rd floor dining room, a CNA walked over to R39, picked up a spoon, and began feeding R39 while standing the entire time. The CNA continued feeding R39 until the meal was finished and then removed the clothing protector. On 6/30/26, the DON stated that when staff assist residents to eat, they are expected to sit next to the resident rather than stand over them, and said she could not explain why the CNA stood instead of sitting while feeding R39.
Resident Exposed During Wound Care
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when R45 did not receive privacy during wound care. During observation on 06/30/2026 at 7:48 AM, R45 was turned toward the wall with the bare back side exposed to the door while wound care was being performed. When the clean border foam dressing was dropped on the ground, the LPN opened the door to leave the room to get a new dressing and left the door open while looking for another dressing. Another surveyor approached and asked the LPN a question, and the door remained open with R45's buttock exposed to the hallway. At 7:49 AM, the ADON used a foot to kick the door shut while supporting R45 on R45's side with the bare backside still facing the door. During interview, the ADON stated they felt a breeze and realized the door was open and was concerned R45 was exposed to the hallway. The DON stated that should not happen. R45 later stated they did not notice the door being open because they were facing the window, but preferred the door shut so they were not exposed.
PRN Psychotropic Order Lacked Required Stop Date and Rationale
Penalty
Summary
The facility did not ensure that a resident receiving a PRN psychotropic medication had an order limited to 14 days or that the record contained a documented rationale for continued use. Resident R5, whose diagnosis includes anxiety disorder, had a PRN lorazepam order dated 5/14/26 for 0.25 mg by mouth every 8 hours as needed for anxiety, but the physician order did not include an end date. The record also did not contain documentation supporting extension of the PRN order beyond 14 days at the time it was reviewed. R5’s psych note dated 5/7/26 documented continued use of lorazepam for anxiety and a panicked feeling, with 0.25 mg every 8 hours as needed and 0.5 mg at bedtime scheduled. The note assessed panic disorder as stable and managed with lorazepam, and stated the resident continued to experience intermittent anxiety and restlessness but remained at behavioral baseline. Additional NP notes dated 6/5/26, 6/12/26, 6/19/26, and 6/24/26 documented anxiety disorder and continued lorazepam use, with the resident described as a high fall risk and the medication regimen continued without increase. On 6/30/26, the DON stated the pharmacist would send recommendations with stop dates and said the psychiatry APNP had not been in since the pharmacy recommendation dated 5/31/26. On 7/1/26, the DON provided a pharmacy recommendation signed by the APNP on 6/29/26 that included a PRN duration of 90 days and a clinical rationale of necessary for psychosocial comfort, but this was not reflected in the resident’s medical record or current orders.
Failure to Complete Significant Change MDS After Hospice Election
Penalty
Summary
The facility did not initiate or complete a comprehensive Significant Change MDS assessment within 14 days after a significant change was identified for one resident who elected hospice services. The resident, admitted with Parkinson's disease, had an admission MDS documenting severe cognitive impairment with a BIMS score of 6, set up assistance for eating, moderate assistance with oral hygiene and bed mobility, dependent toileting, and receipt of PT and OT. The MDS 3.0 RAI Manual dated 10/2025 states that an SCSA is required when a terminally ill resident enrolls in hospice, and the ARD must be within 14 days of the effective date of hospice election. The resident started hospice services on 6/12/2026, but on 6/30/2026, 18 days later, a Significant Change MDS assessment had not been scheduled or completed. During interview, the MDS LPN stated the facility schedules and completes MDS assessments and that a Significant Change MDS is done when a resident starts or stops hospice, with an ARD seven days after signing onto hospice and 14 days to complete the assessment. The LPN was not aware the resident had elected hospice and stated the facility usually learns about hospice in morning meetings, but those meetings had not been occurring consistently.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility did not ensure that a resident with a diagnosis of PTSD received culturally competent, trauma-informed care in accordance with professional standards of practice and the resident’s experiences and preferences. The resident’s record did not contain a PTSD assessment to identify past trauma history, and there was no person-centered PTSD care plan identifying triggers or interventions to reduce or prevent re-traumatization. The facility policy titled Trauma Informed Care states that residents who are trauma survivors will be screened and assessed upon admission to identify any history of trauma and/or PTSD, and that the interdisciplinary team will develop an individualized resident-centered care plan that includes identification of past trauma, triggers, manifestations, and interventions to mitigate re-traumatization. Despite this policy, the resident’s behavior care plan addressed depressed mood, anxiety, and related behaviors, but did not identify the resident’s trauma history, PTSD triggers, or person-centered interventions specific to PTSD. The quarterly social service reassessment also did not address PTSD. The resident’s record showed diagnoses including anxiety, depression, insomnia, ADHD, bipolar disorder, and PTSD, with psychiatric medications and ongoing psych services. The resident’s MDS indicated PTSD as an active psychiatric diagnosis. During observation and interview, the resident stated that being too close to them or loud talking upset them. Staff interviews showed CNA staff had not been told what topics or actions might trigger the resident’s PTSD, and the Social Services Director stated she had never completed a PTSD assessment and did not know much about the diagnosis. The psychiatric provider stated PTSD was a historical diagnosis and could not provide much detail about it, and PTSD was not included in the psychiatric assessment/plan.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility did not ensure the medication error rate remained below 5 percent. Surveyors identified 4 medication errors in 30 opportunities, resulting in a 13.33% medication error rate. The errors involved one resident, R44, during observation of an LPN preparing and administering medications through a G-tube and by mouth. R44 had physician orders for Amantadine HCI oral solution 50 mg/5 ml, Valproic Acid oral solution 250 mg/5 ml, Multivitamins Plus Iron Child Oral Tablet Chewable 18 mg, Thera M Plus oral tablet, Potassium Chloride 20 mEq, and Polyethylene Glycol 3350 powder. During the medication pass, the LPN administered 5 ml of Amantadine HCI instead of the ordered 15 ml enterally two times a day, and 5 ml of Valproic Acid instead of the ordered 24 ml enterally three times a day. The LPN also did not administer the ordered Multivitamins Plus Iron Child Oral Tablet Chewable 18 mg. In addition, the LPN initially administered Polyethylene Glycol 3350 orally rather than by the ordered enteral route after mixing it with Potassium Chloride and water. The DON stated nurses should follow physician orders during medication pass, and was informed of the four observed medication errors.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection during medication administration for one resident. During observation of medication preparation and administration for R44, the LPN prepared multiple medications, including liquid amantadine hydrochloride, valproic acid, cefuroxime axetil, amlodipine, critical care protein, folic acid, clonazepam, and other medications for administration through the resident’s G-tube. The LPN cleaned the top of the medication cart with a disinfectant wipe after pouring the critical care protein, but did not perform hand hygiene afterward. The LPN continued preparing medications while wearing gloves, including breaking folic acid tablets, and later removed the gloves and discarded them without performing hand hygiene. The LPN then entered R44’s room wearing gloves and a gown, and surveyor observation showed no hand hygiene after glove removal. In the room, the LPN checked the resident’s blood sugar, removed gloves again, requested a new pair, and put on fresh gloves without performing hand hygiene after removing the prior gloves. The LPN then flushed the resident’s G-tube and administered the medications, flushing between medications and at completion. Later, the LPN rinsed the syringe used for medication administration, removed gloves, removed the gown, and cleansed hands at the medication cart. On interview, the DON stated the expectation during medication pass was at least alcohol-based hand sanitizer between patients, or soap and water if contamination was known, and confirmed that hand hygiene should be performed after removing gloves.
Missing Pneumococcal Immunization Education and Refusal Documentation
Penalty
Summary
The facility did not ensure pneumococcal immunization education was provided and the resident’s refusal or acceptance was documented for one sampled resident. The facility policy required that each resident or resident representative receive education about the benefits and potential side effects of the pneumococcal vaccine before it was offered, and that the medical record document both the education and whether the vaccine was received, refused, or medically contraindicated. The resident was admitted to the facility and was due to receive the Prevnar 20 vaccination. Review of the immunization record found no documentation that the resident was educated about the pneumococcal immunization and no documentation of refusal or acceptance in the medical record. During interview, the DON and ADON stated that they or the second shift nursing supervisor would approach new residents about immunizations and document the education and response, but after reviewing the record they agreed there was no documentation for this resident. The DON also stated the hospital discharge paperwork showed the resident had declined the immunization at the hospital, but the facility still had the obligation to present the same information upon admission.
Missing COVID-19 Vaccine Education and Refusal Documentation
Penalty
Summary
The facility did not ensure COVID-19 immunization education was provided and the refusal was documented for one resident who was reviewed for immunizations. The resident was admitted to the facility and was due to receive the COVID-19 vaccination, but there was no documentation in the medical record showing that education about the benefits and potential side effects of the vaccine had been provided or that the resident had accepted or refused the vaccine. The facility policy required that before offering the COVID-19 immunization, each resident or resident representative receive education regarding the benefits and potential side effects of the vaccine, be offered the vaccine unless medically contraindicated or already immunized, and have the medical record document education and whether the vaccine was received, refused, or not given due to contraindication. During interview, the DON and ADON stated that they approach new residents with immunization information and document the education and the resident’s acceptance or refusal. When the surveyor identified the missing documentation, the DON reviewed the record and agreed there was no documentation. The DON also stated the resident’s hospital discharge paperwork showed the resident had declined the immunization at the hospital, but the facility still had the obligation to present the same information upon admission.
Failure to Document and Investigate Resident Grievances Related to Alleged Rough Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to address care concerns raised by a resident’s representative. The facility’s written grievance policy, revised 2/12/25, requires that when a grievance is noted verbally or in writing, staff attempt to resolve the issue or direct the complainant to appropriate leadership, notify the Grievance Officer, record identifying information and the nature of the matter, route the grievance for investigation, and ensure efforts toward resolution within seven days, including verbal follow-up to the resident. Surveyor review of the grievance log on 2/3/26 showed no documented concerns from the resident or the resident’s representative, despite allegations that concerns had been reported to facility staff. According to the report, the resident’s representative contacted the Director of Care Transitions on two occasions to report concerns about the resident’s care. After care provided on 11/13/25, the representative reported on 11/14/25 that staff became very frustrated when the resident needed frequent adjustments in bed, called the resident names, and yelled at the resident for using the call light and “wasting” staff time by calling so often. Later, following care on 12/22/25, the representative again contacted the Director of Care Transitions on 12/23/25, alleging that a CNA entered the resident’s room extremely agitated and aggressive about the resident having pushed the call light, then came behind the resident, grabbed the resident around the torso, and yanked the resident backward in bed, which the representative stated resulted in fractures to the resident’s left 7th and 8th ribs. The representative reported to the State Survey Agency that they were not aware of any action taken after the first incident and that the resident was transported to the hospital the day after the second incident. During interviews, the Director of Care Transitions acknowledged remembering conversations with the resident’s representative but did not recall the details, did not take notes, and stated he did not work inside the buildings or know the grievance process, and that he would typically forward an email to the DON or Administrator. He had no documentation in his phone or email showing that he communicated these concerns. The DON stated she had spoken with the representative about the 12/22/25 incident, reviewed the resident’s medical chart, and understood the representative wanted to know how the rib fractures occurred, but she did not consider the questions to be an allegation of abuse or a grievance to address, despite the representative’s concern that the CNA’s hurried and angry repositioning could have caused the fractures. The Administrator later acknowledged that the concerns brought forth by the representative should have been handled as a formal grievance and investigated, but no grievance entry, investigation, or documented resolution was found for these concerns.
Failure to Report Alleged Abuse and Injury of Unknown Source
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of possible abuse or mistreatment to the State Survey Agency as required by regulation and by its own Abuse Prevention Program policy. The policy states that any allegation of abuse or any incident resulting in serious bodily injury must be reported to required regulatory agencies immediately, but not more than two hours after the allegation, and that other reportable incidents must be reported within 24 hours. Despite this, the facility did not report an incident in which a resident developed new rib fractures associated with staff repositioning, nor did it report subsequent concerns raised by the resident’s representative that the CNA had been angry and aggressive during care. The resident involved had multiple significant comorbidities, including a left pelvic fracture, chronic respiratory failure, severe protein-calorie malnutrition, muscle weakness, dysphagia, sacral pressure ulcer, GERD, repeated falls, osteoporosis, and a history of multiple fractures, including rib fractures. The care plan and physician orders required Q2–3 hour repositioning with a wedge and assistance of one staff for bed mobility and transfers. On the date of the incident, while being repositioned in bed by a CNA, the resident complained of severe sharp, stabbing pain in the left ribs, with pain on palpation. A nurse assessed the resident, administered PRN Tramadol without effective relief, and the resident was sent to the ER, where imaging showed suspected new fractures of the left 7th and 8th anterior ribs along with old bilateral rib fractures and thoracic compression fractures. Following the incident, the resident’s representative reported to facility leadership that the CNA had entered the room extremely agitated and aggressive about the call light, and that the CNA allegedly grabbed the resident around the torso from behind and yanked her backward in bed, which the representative believed caused the rib fractures. The representative also reported these concerns to the State Survey Agency. The DON acknowledged speaking with the CNA, who reported hearing a “crack” while repositioning the resident, and acknowledged speaking with the representative, who questioned how the fractures could have occurred when repositioning had been done many times previously without incident. The DON and Administrator stated they did not initiate an abuse investigation or report the incident to the State Survey Agency because, based on the resident’s history of fractures and comorbidities, they did not consider the event or the representative’s concerns to be an allegation of abuse or neglect, and as of survey exit the facility could not provide additional information explaining why the potential mistreatment was not reported.
Failure to Investigate Alleged Abuse After Resident Sustained Rib Fractures During Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of possible abuse or mistreatment/neglect after a resident sustained new rib fractures associated with staff-assisted repositioning. The facility’s Abuse Prevention Program policy requires that all incidents be documented and that, for injuries not initially involving an allegation of abuse or neglect, an appointed investigator gather facts to determine whether the injury should be classified as an injury of unknown source. The policy further requires that the investigator, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, the resident if interviewable, and other residents and employees who regularly interacted with the accused staff member, as well as review written statements and pertinent medical records. The resident at issue had multiple significant comorbidities, including a left pelvic fracture, chronic respiratory failure, severe protein-calorie malnutrition, muscle weakness, dysphagia, sacral pressure ulcer, GERD, and a history of repeated falls. The resident’s care plan and physician orders specified that she required assistance of one staff member for ADLs, toileting, and bed mobility, with Q2–3 hour repositioning using a wedge from right side to back, and that she was fragile with multiple prior fractures. On the evening in question, while being repositioned in bed by a CNA, the resident complained of severe sharp, stabbing pain in the left ribs upon palpation. The CNA reported hearing a “crack” during repositioning and notified the nurse, who assessed the resident, administered PRN Tramadol, and subsequently sent the resident to the ER when pain remained uncontrolled. Hospital imaging identified suspected new fractures of the left 7th and 8th anterior ribs, along with old bilateral rib fractures and thoracic compression fractures. Following this event, the resident’s representative reported concerns to facility leadership that a CNA had entered the resident’s room agitated and aggressive about the use of the call light, and allegedly grabbed the resident around the torso and yanked her backward in bed, which the representative believed caused the rib fractures. The representative also reported to the State Survey agency that they were not aware of any action taken after the first incident and that the resident was transported to the hospital the next day for the second incident. Despite these concerns, the DON stated that she concluded no investigation was needed, relying on the physician’s opinion that the injury was of known source due to the resident’s comorbidities and fragility. The DON acknowledged speaking only with the CNA involved and not interviewing other staff on duty, other residents, or others who might have knowledge of the CNA’s demeanor or any issues between the CNA and the resident. The DON also stated she did not consider the representative’s questions and concerns as an allegation of abuse or neglect. As of survey exit, the facility was unable to provide additional information explaining why a thorough investigation into potential mistreatment during the repositioning was not conducted, contrary to the facility’s own abuse investigation procedures.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for all residents on the 3rd floor, as evidenced by multiple observations of unsanitary conditions. Surveyors noted dirty, stained carpeting throughout the resident hallway, a persistent urine odor in the hallway, and debris including dead insects in most of the ceiling light fixtures. Additionally, two fans in the resident dining area were observed to be covered in dirt, dust, and debris, and the floor transition area of the back elevator was found to be littered with food particles and debris, which interfered with the elevator's operation until the surveyor manually cleared some of the obstruction. Further observations on subsequent days confirmed that these conditions persisted, with the same urine odor, dirty carpets, debris in light fixtures, and unclean fans remaining unaddressed. The hallway carpet was also found to have scraps from breakfast, paper lids, and condiment package pieces. The elevator continued to have food particles and a wrapper in the door slides, and the fans in the dining area remained caked with dust and debris, especially concerning given their proximity to resident food service areas. Interviews with the Environmental Services Director and Maintenance Supervisor revealed a lack of established cleaning schedules or documentation for the cleaning of carpets, light fixtures, and fans. Housekeeping staff were not responsible for full carpet cleaning, only spot cleaning, and there was no routine schedule for cleaning light fixtures or fans. The facility contracted out carpet cleaning services, but could not provide any invoices, contracts, or records to verify when cleaning had last occurred. Maintenance and environmental services staff indicated that cleaning was performed only when dirt was noticed or reported, rather than on a scheduled basis, and no documentation or logs were maintained to track these activities.
Inadequate Infection Control and Water Management in Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of a comprehensive water management plan and improper use of personal protective equipment (PPE) for a resident on droplet precautions. The facility did not have a current water management plan that included specific flow charts to identify areas of concern or interventions for closed units to prevent the spread of pathogens like Legionella. The Environmental Service Director admitted to not keeping up with documentation, and the water management binder lacked evidence of a risk assessment or plan for the closed 2nd floor unit. Observations revealed that the 2nd floor closed unit was in disarray, with dirty hallways and rooms containing garbage, debris, and equipment. Toilets in the unit were either dry or contained water with rust and debris, indicating a lack of regular flushing and maintenance. Despite claims from the Environmental Service Director that weekly flushing occurred, there was no documentation to support this, and the facility's water management plan did not address the specific risks associated with the closed unit. Additionally, the facility failed to ensure proper PPE usage for a resident on droplet precautions. A resident with multiple chronic conditions, including pneumonia, was placed on droplet precautions, but staff did not consistently wear the required PPE, such as masks and eye protection, when entering the resident's room. The Director of Nursing was unaware of the need for eye protection under droplet precautions, and the PPE carts lacked necessary items like face shields. This oversight in infection control practices had the potential to affect all residents in the facility.
Failure to Provide Written Transfer Notices to Residents
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to five residents (R8, R9, R19, R41, and R42) or their representatives, as required by state and federal regulations. Each of these residents was transferred to the hospital due to a change in condition, but there was no evidence that they or their representatives received the necessary written notice, which should include the reason for the transfer, the effective date, and the location to which the resident was transferred. The facility's policy mandates that such notifications be provided in writing and in a language and manner that the resident or their representative understands. For R8, the facility's records showed that the resident was agreeable to the transfer, but there was no written notification with a signature from the resident or their representative. The Nursing Home Administrator (NHA) admitted that sometimes due to the emergent nature of hospitalizations, the floor nurse might not obtain a signature, and in such cases, verbal communication is used, but this was not documented. Similarly, R9 was transferred without a written notice, and the NHA stated that while they try to send the Transfer Notice with residents, it is not part of the transfer paperwork to the hospital. R19, R41, and R42 also did not receive written notifications of their transfers. In R19's case, the NHA provided a notification signed by themselves, indicating a verbal discussion, but not by the resident or their representative. For R41 and R42, the facility was unable to provide any evidence that the residents or their representatives were notified in writing about the transfer and discharge. The surveyor noted these deficiencies and requested additional information, but the facility did not provide further documentation.
Failure to Administer Timely Vaccinations
Penalty
Summary
The facility failed to ensure that each resident was offered pneumococcal and influenza immunizations as required by state and federal regulations. Two residents, identified as R10 and R20, did not receive the pneumococcal vaccine as requested. Additionally, R20 did not receive the influenza vaccine for the current season. The facility's policy mandates that residents be offered these immunizations unless medically contraindicated or already administered, but this was not adhered to in these cases. R10's medical record indicated a pending pneumococcal immunization consent confirmed by the Director of Nursing (DON) on 10/25/23, yet the vaccine had not been administered by the time of the survey. The DON mentioned that the pharmacy coordinates vaccine clinics and waits until 15 residents need the vaccine before scheduling, which led to delays. Similarly, R20's record showed a pending pneumococcal immunization consent confirmed on 12/6/24, and the influenza vaccine administered in March 2024 was for the previous season, not the current one. The DON acknowledged these oversights during the survey.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident. Specifically, the resident did not receive the prescribed strength of folic acid, as the facility administered a stock medication at a different dose. Additionally, the facility did not have the resident's Disulfram medication available for administration. The facility's medication policy requires that medications be administered as prescribed, following the Five Rights of medication administration. The resident was admitted with diagnoses including dementia and was prescribed folic acid and Disulfram for alcohol abuse disorder. During a medication administration observation, a Med Tech administered a 400 mcg dose of folic acid instead of the prescribed 1 mg. The Disulfram was not administered as it was not available in the facility. The MAR indicated discrepancies in the recorded administration of these medications, and interviews with facility staff confirmed the unavailability of the medications and the error in dosing.
Failure to Prevent Accident Hazards and Implement Fall Interventions
Penalty
Summary
The facility failed to eliminate accident hazards and provide adequate supervision to prevent accidents, affecting all 22 residents on a specific unit. Among these residents, several had cognitive impairments, including moderate and severe cases. A significant issue was identified with the storage and supervision of insulin and blood glucose medications. On multiple occasions, a treatment cart containing these medications was left unattended and accessible, contrary to the facility's policy that requires medications to be locked when not in use. This lapse in protocol was confirmed through observations and interviews with staff, including LPNs and the Director of Nursing. Additionally, the facility did not implement fall interventions for a resident with a high risk of falls, identified as R3. R3's care plan included specific interventions such as using a body pillow, maintaining the bed at the lowest position, and providing a soft touch call light. However, these interventions were not consistently in place. Observations revealed that R3's bed was often not at the lowest position, the body pillow was missing, and the call light was not the soft touch type as required. These deficiencies were noted over several days, indicating a failure to adhere to the care plan designed to prevent falls. R3, who has Alzheimer's Disease, dementia, and other health conditions, was assessed as having severe cognitive impairment and required substantial assistance for daily activities. Despite these needs, the facility did not ensure that the necessary safety measures were consistently applied. Interviews with staff confirmed that the care plan and Kardex were not followed, leading to potential safety risks for R3. The lack of adherence to established protocols and care plans highlights significant deficiencies in the facility's supervision and accident prevention measures.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Allis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunrise Health Services | 1.7 mi | ★★★★★ | 1 | 0 |
| Mercy Health Services | 1.7 mi | ★★★★★ | 3 | 0 |
| St Ann Health And Rehabilitation Center | 1.9 mi | ★★★★★ | 11 | 0 |
| Maplewood Center | 2.3 mi | ★★★★★ | 3 | 0 |
| Wheaton Franciscan Hc - Terrace At St Francis | 2.3 mi | ★★★★★ | 3 | 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 October 2026) and official state health department websites.