Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aria Of Brookfield during CMS and state inspections, most recent first.
Food was served below the required temperature for three residents. One resident with intact cognition reported cold food and said trays sat on the cart too long, while two residents with severe cognitive impairment received pureed meals measured at 117 F and 125 F during tray line observation. The facility also had prior temperature logs and resident complaints about food temperature, and policy required hot foods to be held and served at least 135 F.
A resident with type 2 DM and major depressive disorder, who had a BIMS score of 15/15, was observed with multiple pills and a capsule on a lunch tray after stating she was taking them on her own. The EMR lacked documentation of a self-administration assessment, and an LPN and the DON confirmed the assessment had not been completed before medications were left at the bedside.
Failure to prepare for a scheduled admission led to a resident being sent back to the hospital. The resident had been approved for SNF/SAR placement after hospitalization for SOB and leg swelling, and management emails announced the admission, but the admitting nurse said she had no notice, no hospital report, and found the room not ready. The LPN told the resident's son and ambulance staff she could not accept the resident, and the resident was returned to the hospital.
Failure to provide complete written transfer and bed-hold notices affected three residents who were sent out for hospitalization. For each resident, the facility documented notices as verbal or incomplete, and the transfer notices did not include the reason for transfer and/or the location of transfer. One resident had a GI bleed, another was sent out after vomiting and fever with a UTI history, and a third was hospitalized for hypoglycemia, acute encephalopathy, increased troponin, and syncope.
A facility failed to accurately transcribe physician narcotic orders to the MAR for two residents. One resident’s Suboxone orders conflicted between the MAR and narcotic sign-out sheets, with the EMR reflecting a reduced dose that was not approved by the physician and a later renewal based on the incorrect MAR information; the DON also confirmed the resident went without the medication for two days. Another resident’s oxycodone order was transcribed as TID on the MAR even though the handwritten physician order and narcotic sign-out sheet documented BID, and the DON confirmed the resident received three scheduled doses instead of doses 12 hours apart.
A resident with amputations and intact cognition received oxycodone under an order that was entered into the EMR as TID even though the handwritten order and narcotic sign-out sheet reflected BID. The MAR and narcotic record showed multiple doses given at intervals that did not match a 12-hour schedule, and the DON confirmed the order had been incorrectly transcribed and the doses were not 12 hours apart.
A resident with severe cognitive impairment, a feeding tube, and a recent ischemic MCA stroke s/p hemicraniectomy was admitted after referral review failed to identify the bone flap and helmet requirement. After the resident developed hypotension and was sent to the ER, the DON stated the resident could not return because of acuity and the facility did not accept residents with helmets for that purpose. The DON and Admissions Director stated the resident should not have been accepted because the referral review missed the clinical condition.
Infection control practices were not followed for a resident with MDRO, bacteremia, cellulitis, and wounds who had EBP ordered for wound-related care. A CNA provided incontinent care and changed linens while wearing only gloves, placed soiled linens on the floor instead of bagging them, and then entered another room without hand hygiene after removing gloves. The IP confirmed CNAs are to gown up for high-contact care, keep soiled linens contained, and perform hand hygiene after glove removal.
A resident with an activated POA had a grievance after the POA reported that a CNA had purposely unplugged the resident’s call light and voiced concerns about the resident’s care to the facility social worker. Facility policy required prompt investigation and verbal follow-up, including identification of the department head, steps taken, and final results. Administration later acknowledged knowing the POA had concerns but stated they were not aware of the complaint until surveyors informed them and that they did not follow up because they could not reach the POA. The POA reported receiving no updates or information about the investigation, and the facility failed to provide the required feedback and timely resolution of the grievance.
Surveyors observed that medications were not stored securely and expired medications were not handled according to facility policy. On a crash cart, three packs of Tiotropium Bromide Monohydrate inhalation powder labeled for a resident, including one used inhaler with a past use-by date, were found sitting on top of an unlocked, unsecured cart. The ADON acknowledged these inhalers should not have been left unsecured and should have been placed in the designated medication room for expired medications, contrary to the facility’s written medication storage policy requiring secure access and removal and destruction of expired drugs.
A resident with reduced mobility and muscle weakness, who was cognitively intact and care planned for assistance with toileting, activated a call light requesting help with a bedpan due to diarrhea and concern about soiling herself. Surveyors observed the call light on for 57 minutes before an ADON entered, asked what was needed, and provided assistance. During this period, multiple staff, including dietary and housekeeping personnel and a CNA responsible for the resident, entered or were aware of the situation but did not address the call light or provide the requested toileting assistance. This response time exceeded the facility’s stated expectation of responding to call lights within 15–20 minutes and did not follow the written call light procedure requiring timely response and completion of the resident’s request before turning off the call light.
Two residents with hemiplegia and significant ADL dependence were found without accessible call lights, despite care plan interventions and facility policy requiring call lights to be within reach. In one case, a resident with moderate cognitive impairment had the call button hanging below mattress level on the bedframe after staff set up a meal, and the resident did not know its location until a CNA later repositioned it. In another case, a resident who needed extensive assistance for mobility and toileting had the call light buried under linen on a chair, reported needing to be changed and frequently resorted to calling the main facility line for help, and remained without assistance for an extended period because staff were unaware of the need due to the inaccessible call light.
A cognitively intact resident with multiple chronic conditions reported that personal AirPods, believed to have been left in her room before a hospitalization, were missing. Facility staff used the resident’s iPhone link to track the device and found the AirPods in the possession of an LPN. The facility’s abuse prevention policy defined such conduct as misappropriation of resident property, and the incident was substantiated as staff misappropriation of a resident’s belongings.
The facility failed to ensure ordered wound treatments were consistently completed and documented for two residents with surgical and non-pressure wounds. One resident with a right femur fracture and surgical wounds to the right knee and shin had multiple days where daily wound care orders were not signed off on the TAR, with no documentation that treatments occurred. Another resident with a left BKA and a right foot surgical site had daily and M/W/F wound care orders, yet multiple treatment dates lacked documentation despite the resident reporting that dressings were changed and dressings being observed as dated. The wound treatment nurse stated she typically performed weekday wound care but admitted to poor documentation and was unsure who notified staff to cover treatments when she was absent, while LPNs reported they did not sign off wound care because wound nurses did it and they had not received text notifications instructing them to perform wound treatments. The DON stated that wound care was not considered completed if not documented and that documentation of treatments was expected per facility policy.
Two residents with pressure ulcers did not have their ordered wound treatments consistently documented as completed. One resident with a stage 3 toe ulcer and another with an unstageable sacral ulcer had daily and PRN wound care orders, but multiple dates on their TARs showed missing sign-offs with no evidence the treatments were done. The wound treatment nurse reported doing weekday treatments but admitted poor documentation, and stated that floor nurses were to perform treatments when she was absent and notified by text. Floor LPNs reported they did not sign off wound care because wound nurses handled it and that they had not received text notifications to complete wound treatments on the relevant days. The DON stated that wound care was considered not completed if not documented and that documentation of treatments was expected per facility policy.
The facility failed to follow physician orders, care plans, and internal policies for monitoring weights and nutritional intake for three residents with conditions such as diabetes, CHF, dysphagia, malnutrition, and visual impairment. Significant, unplanned weight losses were identified by the RD, but ordered weekly and monthly weights were not consistently documented, reweights requested by the RD were not recorded, and MDS assessments later showed no or unknown weight loss. Meal and supplement intakes were not routinely charted, despite care plan directives to monitor and record PO intake every meal, and one resident repeatedly refused ordered supplements without documented notification to the RD or physician. Observations showed residents with largely uneaten trays, difficulty seeing or accessing food, and poor appetite, while dietary staff did not record intakes and nursing leadership acknowledged that weight refusals and meal intakes were not consistently documented, contrary to facility policies on nutrition/hydration status and weight management.
A resident with end stage renal disease and an order for hemodialysis three times weekly did not receive a scheduled dialysis treatment when staff failed to ensure timely transport and access to a dialysis chair. The resident was rescheduled to an earlier time to accommodate an afternoon appointment, and a CNA began preparing the resident but left her on a bedpan and did not return. By the time day-shift staff and an LPN became involved, night shift reported they could not secure a dialysis chair, and the dialysis unit had no later availability, resulting in the resident missing the ordered dialysis session despite a care plan and facility policy requiring that needed dialysis services be provided.
Two residents with pressure injuries did not receive timely and appropriate assessment or treatment upon readmission. One resident was not assessed by an RN and developed multiple Stage 3 pressure injuries before being seen by a wound physician, with no preventive interventions documented. Another resident with a Stage 3 toe ulcer had no treatment ordered or completed for several days after readmission, and the care plan interventions were not promptly implemented. Staff interviews and observations revealed inconsistent communication and adherence to pressure injury protocols.
Inaccurate PBJ Staffing Data Submission: The facility did not ensure that mandatory PBJ staffing data submitted to CMS was accurate and based on payroll and other verifiable, auditable data. Survey review found the facility was triggered for excessively low weekend staffing, while the facility’s assessment and schedules did not identify low weekend staffing and call-ins were replaced in most cases. The DOR stated he only enters the staffing data and had not seen indications of low staffing, and the NHA said she was not aware of low weekend staffing.
A facility failed to provide required written transfer notice information, including appeal rights and contact details, for multiple residents sent to the hospital. Records for five residents showed hospital transfers for changes in condition or after a fall, but no documentation of the required notices was found. The NHA stated the Social Worker handled bed-holds and the floor nurse provided transfer notices, yet no written notices were produced and no policy or procedure for transfer notice requirements was available.
The facility failed to maintain proper controlled substance counts and medication refrigerator monitoring, and an LPN found a resident with rib fractures still wearing a Lidocaine patch that had been dated several days earlier. Narcotic count logs on one unit lacked required dual signatures, a medication fridge log had not been updated, and staff could not locate a thermometer in the fridge. The resident’s MAR showed the Lidocaine patch as given and removed only on the admission date, even though the order was for daily morning application and bedtime removal.
Improper storage and labeling of medications were observed on medication carts, including controlled narcotics left in the top drawer instead of the narcotic lock box, an unlabeled syringe with unknown clear liquid, loose unknown pills, and multiple stock medications past expiration. Surveyors also found several insulin pens for multiple residents without open dates or beyond the discard period, along with other unlabeled or expired medications on more than one cart.
Food items were found stored improperly in the main kitchen and in resident refrigerators. Surveyors observed partially used oatmeal without labels or dates, expired egg salad, and open items such as prune juice and thickened lemon water without open or use-by dates. Additional resident refrigerators contained numerous unlabeled food items and liquid spills, and a freezer had an unknown frozen brown substance. Staff acknowledged that items should be labeled and dated.
Staff failed to follow infection control practices during care for residents on Enteric Contact Precautions and EBP. Observations showed staff entering a C. diff isolation room without required PPE or hand hygiene, housekeeping moving between the isolation side and roommate’s side without changing gloves or cleaning hands, and a CNA and social service director entering the room without proper precautions. Other observations showed an LPN using unsanitized vital sign equipment between residents and a dirty eye wash station/sink in the medication room.
A resident with an indwelling catheter and intact cognition was repeatedly observed with the catheter drainage bag uncovered and visible in public view, including on the bed and wheelchair facing the door. The resident stated the catheter itself was bothersome and preferred the bag be covered so others could not see it. The DON and NHA were interviewed about the dignity concern, and the NHA stated the bag should be covered.
A cognitively intact resident with CHF, DM2, ESRD on dialysis, malnutrition, and anemia was not fully informed of a change to diet orders and did not consistently receive the requested double portions at meals. Records showed the resident asked for double portions, but the order was later changed to double proteins, the diet slip did not reflect double portions, and the resident reported receiving only partial increases in food items. The DM stated the resident was not updated on the diet change, and the NHA said residents should be informed of diet changes before they occur.
A resident with metabolic encephalopathy and anxiety had PRN lorazepam ordered on admission with no stop date, and the order remained active beyond the 14-day limit for psychotropic PRN meds. The resident received the medication 22 times, no physician reassessment was documented at 14 days, and the DON acknowledged the order should have been discontinued after 14 days.
Enteral feeding tubes were not properly managed for two residents. One resident with a PEG tube had physician orders for bolus Nepro and flushes, but PEG site care was not documented on the TAR, and unlabeled fluid-filled feeding bags were found in the room. Another resident with a G-tube had hanging tube feeding bags and tubing that were initially unlabeled and undated, and later were only dated without any label identifying the contents.
A resident with COPD, chronic respiratory failure with hypoxia, and pulmonary hypertension was observed receiving oxygen by nasal cannula without an oxygen order in the EMR. The resident said oxygen was on all the time, while an LPN could not find the ordered flow rate and had to contact the doctor. The hospital discharge summary listed continuous oxygen at 5 L, and the DON later stated the missing order was found there.
Medication administration errors exceeded the 5% threshold, with 7 errors in 27 opportunities. An LPN gave one resident several meds orally even though the package and orders directed G-tube administration, another resident received the wrong vitamin D dose, and a third resident was given expired calcium carbonate. The facility's medication administration policy required the 5 rights and administration according to prescriber orders.
A resident admitted with lung cancer and palliative care needs was receiving hospice services, but the EHR did not contain a hospice order or a hospice care plan. Surveyors found hospice visit logs in a binder at the nurse’s station, along with unrelated orders for no driving while on narcotics and PRN morphine, while the SSD confirmed the hospice order and care plan were missing from the record.
A resident with severe cognitive impairment and multiple medical conditions alleged being hit in the head by a CNA during care. Although the incident was reported to facility management and the resident’s POA soon after discovery, the required initial report to the state survey agency was not submitted within the mandated two-hour window, as the administrator delayed submission to gather more details.
Surveyors found that the facility's security alarm system only provided audible and visual alerts at the One South nursing station and near the front entrance, leaving other critical care areas without notification when the alarm was triggered. Staff in other units, including a CNA and an RN, confirmed they could not hear the alarm, and facility leadership acknowledged the lack of facility-wide alert capability.
Nurses did not consistently sign narcotic count sheets or verbalize medication and resident names during shift change counts for multiple medication carts. Observations and interviews confirmed that the required process for controlled substance accountability was not followed, resulting in numerous missing signatures and incomplete documentation.
A resident with severe cognitive impairment was physically abused by a family member during a visit, when the family member threw a remote and struck the resident on the forehead. Despite having an abuse prevention policy, the facility failed to prevent this incident, as confirmed by staff interviews and documentation.
Medications and biologicals were left unsecured on a nursing unit, with 15 medication cards left openly on a desk and two unattended medication carts found unlocked and accessible. An LPN confirmed the medications should have been secured after pharmacy delivery, and the Director of Quality Assurance verified that facility policy requires all medications and carts to be locked when unattended.
The facility experienced significant staffing shortages during a weekend, leading to inadequate care for residents. Interviews revealed long wait times for assistance, with one resident left wet for 90 minutes and another experiencing delays in call light responses. Management acknowledged the issue, citing a staff party as a contributing factor, but did not use agency staff to fill gaps.
A resident was prescribed multiple psychotropic medications without obtaining the necessary written consent from their activated Health Care Power of Attorney (HCPOA). Despite the facility's policy requiring signed consent, no documentation was found in the resident's electronic health record, and the HCPOA confirmed they had not signed any consents. The facility's administration was informed of the deficiency, but no further information was provided to address the issue.
The facility failed to provide prior written notice to four residents regarding room changes, as required by their policy. A resident was moved without prior notice or a choice of rooms due to safety concerns, but there was no documentation of the incidents. Another resident was transferred without a choice or documented reason, and two residents with impaired decision-making abilities were moved without notifying their HCPOAs.
A resident reported that a CNA refused to assist her with using a bedpan, instructing her to use her diaper instead. The resident informed another CNA, but the allegation was not reported to the NHA or State agency as required. The facility's policy mandates immediate reporting of such incidents, but the NHA was unaware until informed by a surveyor.
A resident reported neglect when a CNA refused to assist with a bedpan, instructing the resident to use a diaper instead. The incident was reported to another CNA, who failed to escalate the allegation, allowing the accused CNA to continue working. This violated the facility's policy requiring immediate removal of staff accused of neglect.
A resident with moderate depression did not have a comprehensive person-centered care plan addressing mood/psychosocial needs, despite being prescribed medications and treated by a psychologist. The facility's policy requires such plans, but the resident's care plan lacked specific interventions. The issue was confirmed by staff and noted during a surveyor's review.
Two residents in an LTC facility did not receive necessary assistance with activities of daily living. One resident, with multiple health issues, was left without incontinence care for five hours, resulting in a urine-stained sheet. Another resident, with diabetes and renal disease, received only four showers since admission, despite her preference for regular showers. The facility failed to adhere to care plans and documentations, leading to deficiencies in care.
The facility failed to provide adequate supervision and fall prevention for three residents, leading to unaddressed fall risks and unsupervised meals. A resident at high risk for falls did not have proper interventions documented, another was left unsupervised during meals despite choking risks, and a third resident's fall was not thoroughly investigated, lacking witness statements.
A resident with multiple behavioral health diagnoses did not receive necessary services to address significant behavioral changes, including substance abuse issues. The facility failed to update the care plan with new self-harm behaviors and did not conduct a root cause analysis or develop non-pharmacological interventions. Communication lapses between staff and healthcare providers further contributed to the deficiency.
A resident was discharged with discontinued medications, and their scheduled medications were administered late on multiple occasions. The facility did not follow its policies for medication disposal and administration timing, leading to deficiencies in pharmaceutical services.
A resident did not receive their preferred breakfast items and essential dietary supplement, Nepro, as listed on their meal ticket. The resident, who has multiple health conditions including End Stage Renal Disease, expressed that they frequently do not receive meal preferences. The Dietary Manager and Registered Dietitian confirmed the oversight, attributing it to CNAs and Dietary Aides not reading meal tickets properly. The issue was acknowledged by facility leaders.
A long-term care facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and PPE usage. Staff did not perform hand hygiene during incontinence care and wound treatment, and the Nursing Home Administrator entered a COVID-19 isolation room without appropriate PPE. These actions violated the facility's infection control policies.
The facility failed to ensure resident safety, resulting in injuries and uninvestigated falls. A resident was injured during an improper transfer, while others experienced multiple falls without thorough investigation or timely care plan updates. Additionally, a Wanderguard bracelet was improperly placed, potentially compromising its function.
The facility failed to maintain a clean and safe environment, with dining areas and hallways observed to be unclean and unsanitary. Dining areas had dried food debris and stains, and residents were eating in these conditions. Staff interviews revealed confusion over cleaning responsibilities, and maintenance issues such as water-stained ceiling tiles and protruding metal pieces were noted. The Nursing Home Administrator and Director of Nursing were informed, but no corrective actions were detailed.
Food Served Below Required Temperature
Penalty
Summary
The facility failed to ensure food was served at a palatable temperature for three residents, including one resident with intact cognition and two residents with severe cognitive impairment. One resident had diagnoses including UTI, malnutrition, and heart failure, was on a NAS regular diet with thin liquids, and stated that the food was cold because trays sat on the cart too long. During breakfast observation, the resident’s tray was delivered after the breakfast cart had been in progress, and the resident stated the scrambled eggs and pancakes were not warm. The tray did not have an insulated base, only an insulated cover. Two other residents had significant nutritional and medical histories, including Alzheimer’s disease, renal insufficiency, cancer, epilepsy, malnutrition, and severe protein-calorie malnutrition. Both were ordered pureed diets, one with nectar-thick liquids and the other with thin liquids. During tray line observation, two plated pureed meals for these residents were found sitting wrapped in plastic on top of the hot lid of the tilt skillet, and their temperatures were measured at 117 degrees F and 125 degrees F. The dietary manager acknowledged the temperatures were not at 135 degrees F. Additional information in the record showed prior food temperature logs with hot items documented at 110 degrees F, a grievance about food temperature, and resident council concerns about toast quality and heated trays. The facility policy stated hot food items must be held and served at a temperature of at least 135 degrees F, and the dining policy stated meals should be served at a safe and appetizing temperature.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that one resident was assessed for self-administration of medication. The resident had an admission date of 05/17/24 and a readmission on [DATE], with diagnoses including type 2 diabetes and major depressive disorder. The annual MDS with an ARD of 05/06/26 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. During an observation on 07/20/26 at 1:40 PM, 5 pills and one capsule were seen on a napkin on the resident’s lunch tray, and the resident stated she was taking them on her own after lunch. Review of the EMR under the Forms tab showed no documentation of an assessment for self-administration of medications. During interview, the LPN stated she had left the medications in a med cup on the bedside table around 10:00 AM and confirmed the resident did not have a completed self-administration assessment and should not have been left with the medications without confirming administration. The DON also confirmed that an assessment for self-administration had not been completed and should have been done before medications were left at the bedside.
Failure to Prepare for Scheduled Admission
Penalty
Summary
The facility failed to properly prepare for the arrival of a resident who had already been pre-screened and approved for placement, resulting in the resident being returned to the hospital. The resident was expected for admission to the facility for short-term rehabilitation after hospitalization for shortness of breath and leg swelling, and the hospital referral indicated the resident would benefit from skilled therapy and was recommended for SNF/SAR placement. Facility email threads showed the admission was announced to management, including that the resident was coming to the facility on a Sunday at 2:00 PM. During interviews, the Facility Liaison stated the resident was not admitted because the nurse did not know the resident was coming. The RDO stated the facility knew the resident was supposed to be admitted, but the admitting nurse did not receive the information directly and believed weekend admissions were not being taken. LPN10 stated she saw the ambulance arrive but had no idea there was an admission, had no hospital report, found the room not ready and the bed not made, and told the resident's son and ambulance personnel that she could not accept the resident. The resident remained on the stretcher and was returned to the hospital.
Failure to Provide Complete Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer and bed-hold notices that included the reason for transfer and the location to which the resident was transferred for three residents who were hospitalized. For R6, the record showed hospitalization for a GI bleed, and a social worker left a voicemail about a bed-hold while the resident was in the hospital. Family Member 1 stated no paperwork was received when the resident was transferred. The record contained a Healthcare Bed Hold Notice and a Notice of Transfer, but the transfer notice listed only hospitalization as the reason. For R16, the record showed the resident had intact cognition with a BIMS score of 15 out of 15 and was sent to the hospital after vomiting, fever, and physician notification. On readmission, the facility documented that the resident had been hospitalized for a UTI and treated with meropenem. The Bed-Hold and Transfer Notices were documented as provided verbally and not written, and the Notice of Transfer did not include the reason for transfer or the location to which the resident was transferred. The Administrator confirmed the resident was sent to the hospital and acknowledged the missing information on the transfer notice. For R3, the record showed intact cognition with a BIMS score of 15 out of 15 and hospitalization for hypoglycemia, acute encephalopathy, increased troponin, and syncope. The Bed-Hold and Transfer Notices were documented as verbal rather than written, and the Notice of Transfer included only a handwritten note of hospitalization without the reason for hospitalization or the location of transfer. The Administrator stated the representative was telephoned, the notices were mailed, but there was no documentation to prove it, and confirmed the location and reason for transfer were missing.
Narcotic Orders Not Accurately Transcribed to MAR
Penalty
Summary
The facility failed to ensure physician narcotic orders were accurately transcribed to the MAR in the EMR for 2 residents, involving Suboxone for one resident and oxycodone for another. For one resident, the EMR contained conflicting Suboxone orders and the narcotic sign-out sheets did not match the MAR, with the MAR reflecting a 2 mg dose while the narcotic sign-out sheets documented 4 mg. The resident had an admission date in 2024, a BIMS score of 15/15, and the record showed an interdisciplinary team meeting was convened on 04/08/26 to review a medication discrepancy involving Suboxone, but the facility failed to investigate the issue. For the same resident, the DON stated the medication ran out at the end of March 2026, the resident went two days without Suboxone, and the NP wrote a renewal based on MAR information that resulted in the resident receiving Suboxone 0.2 mg for six days. The DON also stated the facility later identified that since 12/17/25 the MAR documented Suboxone 2 mg while the narcotic sign-out sheet documented 4 mg, and that the refill order from the NP was for 2 mg even though the dose the resident had been receiving was 4 mg. The Staff Development/Infection Preventionist stated the pharmacist had recommended a gradual dose reduction from 4 mg to 2 mg in December 2025, but the recommendation was not approved by the physician and the previous DON entered the reduced dose into the EMR; the physician’s narcotic prescription was never changed from 4 mg. For the second resident, the MAR documented oxycodone ER 10 mg three times a day, while the narcotic sign-out sheet documented oxycodone 10 mg twice a day, and the handwritten physician order in the EMR also stated oxycodone 10 mg twice a day. The handwritten order lacked a date and time, and other handwritten narcotic orders in the EMR also lacked dates, times, and notation that the orders had been noted. The DON confirmed the order on the MAR was incorrectly transcribed, resulting in the resident receiving three scheduled doses daily rather than doses 12 hours apart. The pharmacist stated the facility’s process was to send the physician prescription to the pharmacy for filling and that the pharmacy compared the prescription with the narcotic being distributed, but did not verify narcotics with the EMR system.
Incorrect transcription and administration of oxycodone order
Penalty
Summary
The facility failed to ensure that a narcotic was administered in accordance with the physician’s order and the Medication Administration Record (MAR) for one resident who was reviewed for administered narcotics. The resident was admitted with diagnoses including a right below-the-knee amputation and a left foot amputation, and the MDS showed a BIMS score of 14 out of 15, indicating cognitive intactness. During observation, the resident was alert, oriented, and moving around in bed. Review of the July 2026 MAR showed an order for oxycodone HCL extended release 10 mg by mouth three times a day for pain, with administration times set for AM, PM, and HS. However, the narcotic sign-out sheet from the pharmacy documented oxycodone 10 mg one tablet twice a day. The record showed the medication was administered multiple times at intervals that did not match a 12-hour BID schedule, including doses given only a few hours apart on several days. The handwritten physician order in the EMR Misc tab also documented oxycodone 10 mg twice a day, but it was not dated or timed, and the notation lacked a date and time. During interview, the DON confirmed the EMR order had not been correctly transcribed and that the order was for BID, not TID, as entered into the EMR. The DON also confirmed the doses were not 12 hours apart and should have been. The DON and Administrator later stated the physician had been called, but the notification was not documented in the progress notes, and the order had not been changed at the time of the earlier interview, after which the resident received another HS dose only 4 hours and 4 minutes after the PM dose.
Failure to Properly Screen Resident With Hemicraniectomy Before Admission
Penalty
Summary
The facility failed to appropriately pre-screen a resident before admission to determine whether it could meet the resident’s needs and later discharged the resident because it was unable to provide the required care. The resident had an admission MDS with diagnoses including cerebral infarction due to thrombosis of precerebral arteries, hemiplegia following a cerebral infarction on the right dominant side, encephalitis and encephalomyelitis, and a feeding tube. The resident’s BIMS score was 99, indicating severe cognitive impairment. The referral packet from the hospital identified an acute ischemic left MCA stroke status post decompressive hemicraniectomy, and the hospital discharge summary documented acute ischemic MCA stroke status post hemicraniectomy and a left hemicraniectomy. After admission, the resident had low blood pressure and was sent to the ER for evaluation and treatment. Hospital records show the DON called the hospital to state that, due to the patient’s history of craniotomy, the patient could not return to the facility because of acuity. Interviews showed the facility later determined the resident was not appropriate for placement because of the bone flap and helmet used for protection, and the DON stated the facility does not accept residents with helmets for that purpose and does not use physical restraints. The DON stated the facility recognized it should not have accepted the resident, and the FL stated he accepted the resident because the paperwork did not indicate the bone flap and he was unaware the facility could not provide care for that condition. The Admissions Director also stated the resident was not appropriate for placement and that the referral was missed.
Infection Control Breaches During Resident Care
Penalty
Summary
Provide and implement an infection prevention and control program was not followed for one resident with an admission MDS dated 07/15/26 showing diagnoses including MDRO, bacteremia, and cellulitis of both lower limbs and wounds. The resident’s BIMS score was 15 out of 15, indicating intact cognition. The resident had an order for Enhanced Barrier Precautions and a care plan intervention to implement EBP related to wounds, and a skilled daily note stated the resident remained under skilled observation for signs and symptoms of recurrent infection due to a recent history of MRSA bacteremia. During observation, an EBP sign was posted on the resident’s door and PPE was available outside the room, but a CNA was in the room wearing only gloves and no other PPE while handling the resident’s care. Soiled laundry and bed sheets were observed directly on the floor instead of being bagged, and the CNA later placed the items in a hallway bin. The CNA was also observed removing gloves, exiting the room, discarding the gloves, and entering another room without performing hand hygiene. During interview, the CNA stated she did not wear a gown when changing the resident’s brief and bed sheets and said it was acceptable to place soiled linens directly on the floor. The Infection Preventionist stated CNAs are to gown up during incontinent care and changing bed linens, soiled sheets are to be placed in a bag and into receptacles, nothing should be on the floor, and hand hygiene is required after glove removal.
Failure to Provide Required Follow-Up on Grievance Regarding Call Light Disconnection
Penalty
Summary
The facility failed to honor a resident’s right to voice grievances without reprisal by not following its own grievance policy for a resident whose POA reported concerns. The facility’s policy required that all grievances, whether verbal or written, receive immediate priority, be investigated with efforts toward resolution within seven days, and that the resident be provided with verbal follow-up including the name of the department head conducting the investigation, the steps taken, and the final results. The resident, who had an activated POA, was admitted on a specified date, and the POA reported to surveyors that in approximately October a CNA had purposely unplugged the resident’s call light and that she was concerned about the resident’s care. The POA stated she had informed the facility social worker at the time of the event. During a state survey, the POA told surveyors she had not received any information from the facility and was unaware of what was happening with the resident’s care. The facility only submitted a report to the State Agency after surveyors notified them of the complaint on a later date, at which point the facility conducted an investigation and submitted findings to the State Agency. The Nursing Home Administrator acknowledged awareness that the POA had concerns but stated that administration was not aware of the concern until surveyors brought it to their attention and that the facility had not followed up with the POA because they were unable to reach her. The POA reported that she had received no updates at any point during the investigation. As a result, the facility did not provide the required feedback or timely resolution of the grievance as outlined in its grievance policy.
Unsecured and Improperly Managed Inhaler Medications on Crash Cart
Penalty
Summary
Surveyors found that the facility failed to ensure medications were stored securely and that expired medications were removed from active use and discarded appropriately. During a review of crash carts with the Assistant Director of Nursing (ADON), three packs of Tiotropium Bromide Monohydrate inhalation powder labeled with Resident 16’s name, with an expiration date of 01/2027, were observed sitting on top of an unlocked, unsecured crash cart on 2 South. One of the inhalers had been used and had a use-by expiration date of 08/21/25. The ADON acknowledged at the time of observation that these medications should not have been left unsecured on the crash cart and stated that there was a designated medication room for expired medications where such inhalers should have been placed for pharmacy retrieval and disposal. Review of the facility’s January 2018 policy titled “Medication Storage in the Facility” showed that medications and biologicals are to be stored safely, securely, and properly, accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that all expired medications must be removed from the active supply and destroyed in the facility in the usual manner. The observed unsecured storage of labeled inhalers on the crash cart and failure to follow the process for handling expired medications were inconsistent with this written policy.
Failure to Respond Timely to Resident Call Light for Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to respond in a timely manner to a cognitively intact resident’s call light request for assistance with toileting. The resident had diagnoses including reduced mobility and muscle weakness and a care plan that required her call light to be kept within reach and that she receive assistance of one staff member with toileting. On the day of the incident, the resident reported that she had pressed her call light around 11:00 AM because she needed help with a bedpan, believed she might have soiled herself due to diarrhea, and stated that her bottom was sore. Surveyors first observed the call light illuminated above her door at 12:51 PM, with the call button near her hand, and the resident reported that she sometimes waited up to an hour for her call light to be answered and that this occurred almost daily. Between 12:51 PM and 1:48 PM, multiple staff entered the room but did not address the call light or the resident’s request. A dietary aide entered to remove the lunch tray and a housekeeping supervisor entered to remove garbage; neither asked the resident why her call light was on. A housekeeper later entered and, upon leaving, spoke with a CNA across the hall, who stated she was the resident’s aide and that she had to care for residents going to dialysis before assisting this resident. The call light remained on until 1:48 PM, when the ADON entered the room, asked what the resident needed, turned off the call light, and assisted her with the bedpan, 57 minutes after the call light was first observed on by surveyors. The ADON and DON both stated that staff were expected to respond to call lights in a timely manner, with the DON specifying an expectation of within 15 to 20 minutes, and the facility’s call light policy required timely response and that the call light remain on until the request was completed.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves staff failure to ensure resident call lights were accessible as required by facility policy and resident care plans. One resident with hemiplegia and hemiparesis following a stroke, and a BIMS score indicating moderate cognitive impairment, had a care plan intervention directing staff to keep the call light within reach and encourage its use. During observations, this resident was seen in bed after staff had set up breakfast, with the call button hanging over the upper left corner of the bedframe below mattress level and out of reach. Over an hour later, the call button remained in the same inaccessible position, and the resident reported not knowing where it was, stating that staff usually clipped it to the blanket but it might have moved when they sat him up for breakfast. A CNA who was not assigned to the resident confirmed the call button was out of reach and moved it to the tray table. Another resident with hemiplegia and hemiparesis following a stroke required total assistance with most ADLs, extensive assistance of two persons for bed mobility and transfers, and physical assistance for toileting. During observation, this resident was in bed talking on a cell phone while the call light was buried under linen on a chair, out of reach. The resident stated needing to be changed but having no way to call for help, and reported that this situation occurred frequently, leading the resident to call the main facility line and ask for the nursing supervisor for assistance. The resident reported having made such a call about 15 minutes earlier, and approximately 45 minutes later still had not received assistance. When informed, a CNA entered the room and confirmed the call light was not within reach and was located on a chair far from the resident. The DON and Administrator both stated their expectation that call lights be within residents’ reach at all times, and the facility’s written procedure required staff, when leaving a room, to ensure the call light is placed within the resident’s reach and to monitor call light location during rounds.
Failure to Protect Resident Property From Misappropriation by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s personal property from misappropriation. A cognitively intact resident, with a BIMS score of 13 out of 15 and medical diagnoses including multiple sclerosis, spastic hemiplegia affecting the left dominant side, and type 2 diabetes mellitus, reported that her AirPods were missing. The resident believed she had left the AirPods in her room before a hospitalization. The facility’s self-reported incident indicated that staff used the resident’s iPhone link to track the missing AirPods. The AirPods were subsequently located in the possession of an LPN who was employed at the facility at that time. The facility’s abuse prevention policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident’s belongings or money without the resident’s consent, including obtaining property by intentional deception or using personal identifying information. During an interview, the resident confirmed that her AirPods had gone missing and that the facility found the nurse who took them and returned the AirPods. In a later interview, the Administrator was informed that, because the facility substantiated the allegation of misappropriation by its staff, the facility was responsible for the employee’s actions.
Failure to Complete and Document Ordered Wound Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered wound treatments were both completed and documented for residents with non-pressure surgical wounds. One resident with a displaced comminuted fracture of the right femur had orders for daily and PRN wound care to the distal end of the right hip incision (right knee) and right shin, including cleansing with normal saline, application of collagen sheet and xeroform, and coverage with ABD and Kerlix. The resident’s care plan identified a risk for impaired skin integrity with non-pressure wounds to the right shin and right knee and included an intervention to provide skin care per facility guideline and PRN. Review of the Treatment Administration Records (TARs) for this resident showed multiple dates on which the ordered wound treatments were not signed off as completed and remained without documentation, and there was no additional documentation provided to show that the treatments were done on those dates. Another resident with a history of left below-knee amputation and peripheral vascular disease had care plan interventions that included encouraging compliance with the treatment regimen. This resident had orders for daily and PRN wound care to the left BKA surgical wound, involving cleansing with normal saline and packing with Dakin’s-soaked gauze, and separate orders for wound care to a right foot surgical site on a Monday/Wednesday/Friday and PRN schedule, including washing with soap and water and applying betadine and dry gauze. Review of this resident’s TARs for December and January revealed multiple dates on which the treatments for both the left BKA and the right foot surgical site were not signed off as completed and remained without documentation. During observation and interview, the resident reported that wound care was being done every day to the left leg and every other day to the right foot, and both dressings were dated, indicating treatments had been completed earlier in the shift, despite the lack of corresponding documentation on the TARs. Interviews with staff revealed inconsistent practices and gaps in responsibility for wound treatment and documentation. The wound treatment nurse reported that she performed the facility’s wound treatments Monday through Friday, with other wound care nurses covering weekends, and that if she was sick or not working, another nurse or the floor nurses were expected to complete the treatments. She stated that when she was sick, the facility sent text messages to floor nurses to complete treatments, but she was unsure who notified nurses on a specific date when she was absent and acknowledged she was “bad with documenting” treatments on the TAR. Floor LPNs reported that they did not sign off wound treatments on the TAR because wound nurses completed them and that they relied on text notifications to know when they needed to perform wound care; they stated they had not received such texts during the relevant period, including on a date when the wound nurse was out sick. The DON stated that, in general, wound care was not considered completed if it was not documented and that wound care was expected to be documented as completed, with floor nurses responsible for treatments when the wound care nurse was unavailable. The facility’s documentation policy required timely documentation of actual events, including treatments, which was not followed in these instances.
Failure to Complete and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered pressure injury treatments were both completed and documented for two residents with pressure ulcers. For one resident with diabetes, peripheral vascular disease, and intact cognition, the EMR showed an order for daily and PRN wound care to a stage 3 pressure ulcer on the left second toe, including cleansing with normal saline and application of silver sulfadiazine 1% and calcium alginate. The resident’s care plan identified risk for impaired skin integrity and a stage 3 pressure ulcer to the left second toe, with an intervention to provide skin care per facility guidelines. Review of the Treatment Administration Records (TARs) for December and January revealed multiple dates on which the ordered toe wound treatment was not signed off as completed and remained without documentation, and there was no documentation provided that the treatments were completed on those dates. A second resident, admitted with osteomyelitis and diabetes and assessed as severely cognitively impaired, had been admitted with a stage 2 pressure ulcer that received treatment. The EMR contained an order for daily and PRN wound care to a sacral pressure injury, specifying cleansing with normal saline and application of silver sulfadiazine 1% and calcium alginate. The care plan documented an unstageable sacral wound and included an intervention to administer treatments as ordered and monitor for effectiveness. Review of this resident’s TARs for December and January showed that the sacral wound treatment was not signed off as completed on several dates and remained without documentation, with no evidence provided that the treatments were completed on those days. Interviews with staff further clarified the actions and inactions leading to the deficiency. The wound treatment nurse reported she was responsible for wound treatments Monday through Friday and that other wound care nurses completed treatments on weekends, with floor nurses expected to complete treatments if the wound nurse was absent and notified by text. She stated she had been sick on one of the dates in question but otherwise did all wound treatments, and acknowledged she was “bad at documenting” treatments on the TAR. Floor LPNs reported they did not sign off wound treatments because wound nurses completed them and that they had not received text notifications instructing them to perform wound care on the dates in question, despite having worked those days. The DON stated that, in general, wound care was considered not completed if it was not documented and that wound care was expected to be documented as completed, consistent with facility policies on wound management and documentation expectations.
Failure to Monitor Weights and Nutritional Intake for Residents with Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document weights and nutritional intake, and to report significant changes in eating and supplement consumption for multiple residents with known nutritional risks. For one resident with diabetes, dysphagia, and moderate protein-calorie malnutrition, orders were in place for weekly then monthly weights, and the care plan directed that the resident be weighed per facility protocol. The weight record showed an 11.7% loss between late September and mid-October, followed by no documented weights until early January, when an additional 10.5 lb loss was recorded. A nutrition note in mid-October identified a significant, unplanned, and unfavorable weight loss and requested a reweight to confirm accuracy and assess for ongoing change, but there was no documentation of intervening weights or refusals. The quarterly MDS later documented no or unknown weight loss despite these changes, and there was no evidence in the record that the resident refused to be weighed. Another resident with diabetes, morbid obesity, CHF, and glaucoma had two active orders for weekly weights, including daily weights before breakfast and weekly weights for CHF with notification parameters for rapid weight gain. The care plan required monitoring and recording of PO intake and weighing as ordered by the physician. The weight summary showed an 8.7% loss over a short period in October, with no further weights documented afterward. A nutrition note identified a significant, unplanned, and unfavorable weight loss and recommended continued monitoring of intakes and weights per facility protocol. However, there were no documented current weights on the subsequent annual MDS, which recorded no or unknown weight loss, and review of the EMR revealed no documentation of weight refusals or recorded meal intakes. Observations showed the resident repeatedly with largely uneaten breakfast trays, reporting poor appetite, visual difficulty seeing the tray, and variable eating, while staff interviews acknowledged that the ordered weights had not been done and that intakes were not routinely documented. A third resident with protein-calorie malnutrition and dysphagia experienced a documented 6.0% weight loss between late September and mid-October, after which no further weights were recorded despite an order for weekly weights followed by monthly weights. A nutrition note identified this as a significant, unplanned, and unfavorable weight loss, recommended increasing a high-calorie supplement to three times daily, and directed monitoring of PO intake with a goal of 50% of meals and monitoring of weights per facility protocol. The care plan was revised to reflect risk for malnutrition, with interventions to weigh per facility protocol and to monitor and record intake every meal. Medication records showed that the resident did not consume the ordered Proheal supplement on a large number of occasions in December and January, yet there was no documentation that the RD or physician were notified of these refusals, no recorded meal intakes, and no documentation of weight refusals. Observations showed the resident, who was legally blind, unable to see or access food on the tray and not eating, while dietary aides reported they did not record intakes and did not consistently notify nursing when residents ate little or nothing. Nursing leadership and the RD acknowledged reliance on facility protocol for weights, lack of documentation of refusals, and uncertainty about intake documentation, despite facility policies requiring routine monitoring of nutritional status, weighing per protocol, and evaluation of significant weight variances. Facility policies on Nutrition/Hydration Status Maintenance and Weight Management required that residents be provided assistance with eating and drinking as needed, be routinely monitored for changes in nutritional status using data such as weights and intake records, and be weighed monthly or more often as clinically indicated. The policies also required that significant weight variances prompt evaluation, documentation of potential causes, and interventions, and that reweights be obtained for significant changes unless otherwise ordered. In practice, for the three residents reviewed, ordered and policy-required weights were not consistently obtained or documented, significant weight losses identified by the RD were not followed by documented reweights or ongoing monitoring, and meal and supplement intake records were absent despite care plan directives. Staff interviews confirmed that intakes were not routinely documented, refusals of weights were not recorded, and concerns about poor intake were often communicated informally, if at all, rather than through the EMR or formal notification to the RD or physician.
Failure to Ensure Transport and Access to Scheduled Dialysis Treatment
Penalty
Summary
The facility failed to ensure that a resident who required hemodialysis was transported to receive the ordered treatment, resulting in a missed dialysis session. The resident had end stage renal disease and a physician’s order for hemodialysis on Monday, Wednesday, and Friday during the day shift, with instructions that if dialysis was missed for any reason, a BMP lab was to be drawn the following day and reported to the physician. The resident’s care plan identified a need for dialysis three times a week and included an intervention to encourage attendance at scheduled dialysis appointments. The resident was cognitively intact, with a BIMS score of 15, and routinely received dialysis. On the day of the incident, the resident was scheduled for an earlier-than-usual 5:00 AM dialysis time to accommodate an afternoon appointment, and the on-site dialysis center was reported to be full, requiring residents to be switched around. A night-shift CNA began preparing the resident for dialysis and placed her on a bedpan but did not return, leaving the resident unattended until day-shift staff arrived. By the time day-shift staff and the LPN became involved, night shift reported they were unable to find a dialysis chair for the resident, and the dialysis unit had no available chair later in the day, resulting in the resident missing the scheduled dialysis treatment. The DON reported that a night-shift CNA had called about not being able to locate a dialysis chair and was instructed to search the facility, dialysis area, and room and get the resident to dialysis, but the resident ultimately did not receive the ordered dialysis session.
Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice, resulting in deficiencies for two residents. One resident with a history of pressure injuries and multiple comorbidities, including diabetes, morbid obesity, and vascular disease, was readmitted to the facility without a comprehensive skin assessment by an RN. Upon readmission, redness was noted by an LPN on the coccyx and buttocks, but no measurements or detailed characteristics were documented, and no RN assessment was completed. It was not until a scheduled wound physician visit several days later that three Stage 3 pressure injuries were identified and treatment was initiated. Prior to this, there was no documentation of preventive treatments or interventions, such as barrier cream, and no evidence that staff were consistently implementing care plan interventions like repositioning with a draw sheet or using positioning devices. Interviews revealed that staff were unclear about the resident's repositioning needs, and the resident reported never being offered pillows or assistance for offloading pressure. Another resident was readmitted with a known Stage 3 pressure injury to the right fifth toe. Although the wound was documented upon readmission, there were no treatment orders for five days, and no wound care was completed until a week later. The treatment administration record (TAR) did not reflect a scheduled daily treatment order, and the first documented treatment occurred only after the wound physician assessed and debrided the wound. The care plan included pressure-relieving devices and protocols for injury treatment, but these were not implemented in a timely manner. Interviews with the wound nurse confirmed that the treatment order should have been placed and initiated upon readmission, but this did not occur. Observations and interviews throughout the survey period highlighted lapses in communication, documentation, and adherence to facility policy regarding skin assessments and pressure injury prevention. Staff were not consistently aware of or implementing individualized care plan interventions, and there was a lack of timely and comprehensive assessment and treatment for residents at risk for or with existing pressure injuries. These failures resulted in delayed identification and management of pressure injuries, contrary to professional standards and facility policy.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility did not ensure that mandatory PBJ staffing data submitted for the second quarter of 2025 was accurate and based on payroll and other verifiable and auditable data in the uniform format required by CMS. During survey review, the facility was triggered for excessively low weekend staffing. The facility’s assessment was reviewed, including staffing hours and acuity levels of care, and the staffing needs documented in the assessment were compared with the facility’s schedules for 1/1/25 through 3/31/25; no low weekend staffing was identified and call-ins were replaced in most cases. The DOR who submits the PBJ reports stated he only enters the staffing data, does not receive alerts for low staffing, and had not seen indications of low staffing at the facility. The NHA stated she was not aware of low weekend staffing. No additional information was provided to explain why the submitted staffing data was not accurate.
Missing Transfer Notice Information for Hospitalized Residents
Penalty
Summary
The facility did not ensure that residents transferred to the hospital received written transfer notice information that included required appeal rights and related contact information. Record review and interview showed this occurred for 5 of 6 residents reviewed who were transferred out of the facility: R65, R13, R10, R4, and R58. The required notice information was not documented in the medical records for these hospital transfers, and the facility did not provide a policy and procedure related to transfer notice requirements. R65 was transferred to the hospital twice for a change in condition and returned to the facility both times. R65 was in the facility for wound care and stated during interview that they could not recall details of why they went to the hospital. The medical record did not contain documentation of the required notice information for either transfer. When asked, the Nursing Home Administrator stated the Social Worker completes the bed-hold and the floor nurse provides the transfer notice, but later did not provide written transfer notices for R65. R13, R10, R4, and R58 also had hospital transfers for changes in condition or after a fall, and their records did not contain the required transfer notice information. R13 had two hospital transfers for a change in condition; R10 had one transfer for a change in condition and had diagnoses including anemia and heart failure; R4 had one transfer for a change in condition and had diagnoses including anemia, heart failure, and coronary artery disease; and R58 had a hospital transfer after a fall and had diagnoses including metabolic encephalopathy, congestive heart failure, severe protein-calorie malnutrition, chronic kidney disease, and anxiety. For each of these residents, the NHA stated the same process involving the Social Worker and floor nurse, but no written transfer notices were provided, and the facility did not have a policy and procedure for transfer notice requirements.
Pharmaceutical Services and Medication Administration Deficiencies
Penalty
Summary
The facility did not provide pharmaceutical services to ensure proper dispensing of medications, did not keep drug records in order, and did not maintain and periodically reconcile controlled drugs. On 08/26/2025, surveyors reviewed the narcotic count logs for unit 2 South and found multiple dates in both count books where there were not two signatures by licensed nurses, despite the facility policy requiring a physical inventory of all controlled substances at each shift change or when keys are transferred. Surveyors also observed the medication room on 1 East/West and found the medication refrigerator log had not been updated since July 2025, and LPN-Q was unable to locate a thermometer inside the refrigerator. The DON stated that all medication refrigerators should have a thermometer and that temperatures should be logged, and also reported that maintenance had been contacted weeks earlier about a 2 South refrigerator that would not close because of ice buildup. The facility also failed to ensure medication administration for a resident with rib fractures. R120 was admitted with a diagnosis including fracture of the ribs and had an order for Lidocaine 5% patch to be applied every morning and removed at bedtime. On 08/25/2025, an LPN observed a Lidocaine patch dated 8/22/25 still on R120's right rib area when preparing to apply a new patch. The old patch was removed and replaced, and R120 stated she wondered why she had not been getting the patch every day because it helped with rib fracture pain. Review of the MAR showed the patch was signed out as placed in the morning and removed at bedtime from 8/22/25 to 8/22/25 bedtime, even though R120 was admitted in the evening on 8/22/25 and should have had the hospital patch removed that night and then received new patches on 8/23/25 and 8/24/25. No explanation was provided for why the Lidocaine orders were not followed.
Improper Storage and Labeling of Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with accepted professional principles, and controlled substances were not consistently stored in locked, separately secured compartments. Surveyors observed two bottles of controlled narcotic medications in the top drawer of a medication cart rather than in the narcotic lock box, and they also found an unlabeled 1 mL syringe containing an unknown clear liquid in the cart. In addition, nine loose, unknown pills were found throughout the medication cart, and the first two were discarded into the regular garbage. Facility staff stated that the syringe contained heparin for a resident, but it had been left in the cart while the nurse walked away to pass medications to another resident. Surveyors also observed numerous stock medications on medication carts that were past the manufacturer expiration date, including vitamins, calcium carbonate, cranberry liquid, diphenhydramine liquid, aspirin, iron supplement liquid, and inhalers with rubbed-off or missing expiration information. On the second-floor cart, insulin pens for multiple residents were found without open dates or beyond the 28-day discard period after opening, including pens for residents using glargine, lispro, and other insulin products. On the first-floor cart, additional insulin pens were observed unlabeled and used without open dates, including house insulin pens and resident-specific pens for several residents. Facility leadership acknowledged that controlled narcotics should have been in the locked narcotic drawer or sent home with a discharged resident, that drawn-up medication should be labeled if a nurse leaves it unattended, and that medications past expiration should be removed from circulation. The DON stated that medication carts should have open dates on medications and that expired stock medications should be removed from the carts. The observations and interviews documented that the medication carts contained unlabeled, expired, and improperly stored medications at the time of survey.
Food Items Stored Unlabeled, Undated, and Expired
Penalty
Summary
The facility failed to store and prepare food in accordance with professional food service safety standards. In the main kitchen walk-in cooler, surveyors observed 3 bowls of oatmeal that were partially used but not labeled or dated, and a container of egg salad that was labeled with an 8/12/2025 date and a use-by date of 8/19/2025, which had already passed. The supervisor acknowledged that the oatmeal should have been labeled and dated and stated the expired egg salad would be discarded. The facility policy required leftover food to be stored in covered containers or wrapped securely, clearly labeled and dated before refrigeration, and checked to ensure foods were consumed by their safe use-by dates, frozen, or discarded. Surveyors also observed unlabeled and undated food items in resident refrigerators and kitchenettes on both floors. In the 2nd floor kitchenette refrigerator, prune juice and thickened lemon water were found without labels or dates, and the dietary manager stated staff should date items after opening them. In the 2 South medication room refrigerator freezer, multiple food items were unlabeled and there was an unknown brown frozen substance that appeared to be a liquid spill. In the 1 East/West medication room refrigerator, surveyors observed brown liquid spills and numerous unlabeled food items. These observations showed that food storage practices were not being followed in the main kitchen and in resident refrigerators and medication room refrigerators.
Infection Control Failures During Precautions and Medication Pass
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program that was followed during resident care and environmental cleaning for multiple residents on precautions. For a resident on Enteric Contact Precautions for C. difficile, staff were observed entering the room without the required gown, gloves, and hand hygiene, and housekeeping staff were observed cleaning the room and moving between the isolation side and the roommate’s side without changing gloves or performing hand hygiene. Staff also handled trash, linens, cleaning supplies, and a drink on the roommate’s side while still wearing the same gloves used in the contact precaution area. A CNA was also observed entering the room to remove a meal tray without the required PPE or hand hygiene, and a social service director entered the room twice with ice water for both residents without PPE or hand hygiene. The report also documents failures with Enhanced Barrier Precautions for residents with invasive devices and high-contact care needs. One resident with diagnoses including COPD and emphysema had an order for EBP, and staff were observed providing incontinence care and changing wet linens while failing to perform hand hygiene between glove changes and while using an open zinc oxide ointment container. Another resident with EBP for a dialysis catheter and enteral feeding tube was observed receiving meal tray setup and direct contact care from a CNA who was not wearing PPE, and the resident’s doorway did not have the EBP indicator posted at the time of the observation. The DON stated the resident was on EBP and later replaced the sign. Additional observations showed infection control lapses during medication administration and equipment use. An LPN took vital signs on one resident, did not sanitize the vital sign machine afterward, removed gloves without hand hygiene, and then used the same unsanitized equipment on another resident before administering medications. The report also notes a dirty eye wash station and sink in the medication room, with white crusty matter around the faucets and in the sink, and staff stated the sink was not used and maintenance was responsible for it. The facility policies reviewed in the report required gown and glove use, hand hygiene, and cleaning of shared equipment and surfaces, but staff observations did not match those requirements.
Uncovered catheter bag exposed resident to public view
Penalty
Summary
The facility did not ensure that 1 resident with an indwelling catheter received appropriate treatment to enhance self-esteem and provide dignity. The resident, who had diagnoses including acute cystitis with hematuria and chronic kidney disease, had a Medicare admission MDS dated 08/29/2025 documenting intact cognition with a BIMS score of 15. Surveyors observed the resident multiple times with the catheter drainage bag uncovered and visible in public view, including hanging on the bed facing the open door, hanging on the bed facing the door without a cover, and hanging on the wheelchair uncovered. When interviewed, the resident stated that having a catheter bothered them and that if a catheter was necessary, they preferred it to be covered so others could not see it. The DON and NHA were interviewed about the concern, and the NHA stated the bag should be covered.
Resident Not Informed of Diet Change and Preferred Double Portions Not Implemented
Penalty
Summary
The facility did not ensure that R26, a cognitively intact resident with diagnoses including congestive heart failure, type II diabetes, chronic kidney disease stage 5/end-stage renal disease, unspecified protein-calorie malnutrition, and anemia, was fully informed of changes to dietary orders and that the resident’s preference for double portions at mealtimes was implemented. R26’s MDS documented a BIMS score of 15 and that the resident was understood and understood others. The baseline care plan identified risk for malnutrition related to diabetes, end-stage renal disease, dependence on renal dialysis, and in-house hemodialysis, but it did not indicate a preference for double portions or that the resident was on a double protein diet. A dietary progress note documented that the resident requested double portions with meals and that the diet and meal ticket were updated, but later documentation showed the order was changed to double proteins. During interview, R26 stated that double portions were not consistently provided and described receiving only some items in larger amounts, such as eggs without meat and one piece of bread. Observation of the diet slip and tray showed double protein was documented, but not double portions, and the resident called the kitchen to request additional waffles because the meal did not match the resident’s preference. The dietary manager stated the resident was not updated on the diet change when it was made, and the nursing home administrator stated the expectation was that the resident should be informed of diet changes before they occurred.
PRN Psychotropic Medication Exceeded 14-Day Limit
Penalty
Summary
The facility did not ensure psychotropic medications were limited to 14 days when ordered as needed (PRN) for one resident, R58, who was reviewed for unnecessary medications. R58 was admitted with diagnoses of metabolic encephalopathy and anxiety and had an admission order for lorazepam 0.5 mg every four hours PRN with no stop date. The facility policy titled Psychotropic Drug Use, dated 4/1/2025, states PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner documents a rationale for extending the order and indicates the duration. R58’s PRN lorazepam order remained in place beyond 14 days without a documented physician reassessment on 7/22/2025 to determine whether the medication should be scheduled, discontinued, or continued for a determined amount of time. The resident received PRN lorazepam 22 times from 7/8/2025 through 8/2/2025. After the resident was admitted to hospice services, the PRN lorazepam order was changed to lorazepam solution 2 mg/ml, 1 mg IM every four hours PRN for anxiety, agitation, shortness of breath, restlessness, or tachycardia, and no stop date was documented. In interview, the DON stated psychotropic medication needs to be discontinued after 14 days and agreed the lorazepam should have been discontinued after 14 days.
Enteral Feeding Tubes Not Properly Labeled or Documented
Penalty
Summary
The facility failed to ensure appropriate treatment and services for residents with enteral feeding tubes. For one resident with dysphagia and a PEG tube, the physician orders included bolus Nepro after meals if less than 50% of the meal was consumed, free water flushes, and residual checks, but the physician order summary did not include PEG site care and the TAR did not document PEG site care since admission. During observation, the resident was eating breakfast and was not connected to the tube feeding pump, which had a 1-liter bag of clear liquid and a 1-liter bag of brown liquid hanging in the room without identifying labels; the brown liquid bag was dated 8/6 with no identifying labeling, and the clear liquid bag had no identifying labeling. The ADON stated PEG site care was done daily but did not know what happened to the physician orders or TAR documentation and discarded the fluid-filled bags without knowing why they were there. For another resident with paraplegia, Parkinson's disease, cognitive communication deficit, dysphagia, and a G-tube, the care plan identified enteral feeding as necessary to maintain nutritional and hydration status. On observation, the resident had a tube feeding pump running with a 1-liter bag of clear liquid and a 1-liter bag of brown liquid, with 800 mL of brown liquid in one bag, and the tubing was connected to the gastrostomy tube. The hanging bags and tubing initially had no date, time, label, or description of the contents. On a later observation, the bags were dated with black marker, but the liquids still were not labeled and the tubing still had no date or label. The NHA and DON stated nursing staff should label the hanging liquids and the line connecting the bags to the machine, and the NHA stated it was the expectation that staff label, date, and initial the tube feeding bags and line.
Missing Oxygen Order for Resident Receiving Continuous Oxygen
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident receiving oxygen therapy. The resident was admitted with diagnoses including displaced bicondylar fracture of the left tibia, pulmonary hypertension due to lung diseases and hypoxia, COPD, and chronic respiratory failure with hypoxia. The admission MDS documented moderate cognitive impairment with a BIMS score of 12 and that the resident received oxygen. During observation, the resident was lying in bed with an oxygen concentrator delivering 4.5 liters via nasal cannula, and the resident stated the oxygen was on all the time even though the resident felt it was not needed continuously. Record review showed no oxygen order in the EMR when the resident was observed receiving oxygen. The hospital discharge orders indicated the resident was to receive 5 liters of oxygen continuously. During interview, an LPN reviewed the EMR and stated a doctor would need to be called because the oxygen rate could not be found in the record. The LPN later stated the doctor had been contacted and the resident should be on 5 liters. The oxygen order was then entered into the EMR by the DON after the surveyor had already interviewed the LPN. The DON stated the missing order had been found on the hospital discharge summary and that staff should also be checking the resident's pulse oxygenation every shift.
Medication Administration Errors Exceeded 5 Percent
Penalty
Summary
The facility did not maintain a medication error rate below 5 percent during medication administration observations, with 7 medication errors identified out of 27 opportunities for an error rate of 25.93%. The errors involved 3 residents observed during surveyor review: one resident with dysphagia and G-tube placement, one resident with dependence on renal dialysis, and one resident with a rib fracture diagnosis. The facility's medication administration policy required the 5 rights, including the right resident, drug, dose, route, and time, and medications to be administered according to prescriber orders. One resident was observed receiving levetiracetam, Renal Vitamin, atenolol, iron, and amlodipine orally with water even though the medication packages and physician orders indicated administration via G-tube. The LPN stated she had been giving the medications orally since starting at the facility and said she had been told the resident could receive medications orally, although the orders still indicated G-tube administration at the time of review. A second resident was observed receiving 5,000 IU of vitamin D from 5 tablets of 1,000 IU each, while the physician order documented cholecalciferol 50,000 IU weekly. A third resident received calcium carbonate from a stock bottle that was observed to be expired, with the bottle showing an expiration date of 1/25; the LPN stated she had not checked the expiration date before administering it.
Missing hospice order and care plan
Penalty
Summary
The facility did not ensure there were systems in place to coordinate care services between the facility and contracted hospice services for one resident receiving hospice care. The resident was admitted to the facility with diagnoses including malignant neoplasm of the right bronchus or lung, encounter for palliative care, and unspecified protein-calorie malnutrition, and was admitted to hospice with a diagnosis of malignant neoplasm of the lung. Survey review found a discharge summary stating the resident was transitioned to hospice at the facility because home hospice was not possible due to lack of family support at home. Surveyors reviewed the resident’s electronic record and did not find an order for hospice services in the orders section or a hospice focus area in the care plan. A hospice binder at the nurse’s station contained hospice visit documentation, including hospice aide and RN sign-in logs, but no hospice service order. The binder did contain orders for the resident not to drive while on narcotics and for PRN morphine for pain management. During interview, the Social Services Designee stated hospice would address most things, but also confirmed that an order and care plan for hospice services should be in the EHR and were not found at the time of review.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to submit an initial report of an allegation of staff-to-resident abuse to the state survey agency within the required two-hour timeframe for one resident. According to facility policy, any allegation of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property must be reported immediately, defined as no later than two hours after forming the suspicion if serious bodily injury is involved. In this case, a resident with severe cognitive impairment and a history of chronic kidney disease and major depressive disorder reported being hit in the head by a CNA during care. The allegation was discovered by facility management after the resident’s POA reported observing the incident on camera and after the resident made a direct accusation to staff. Facility documentation shows that the incident was discovered at approximately 9:08 AM, but the initial report to the state survey agency was not submitted until 1:27 PM, exceeding the two-hour reporting requirement. The administrator confirmed that the report was delayed because she waited to obtain more details before submitting it. The deficiency centers on the failure to promptly report the abuse allegation as required by both facility policy and regulatory standards.
Failure to Ensure Facility-Wide Security Alarm Notification
Penalty
Summary
Surveyors observed that the facility failed to ensure its security alarm system was capable of alerting staff throughout the entire building when triggered. On the morning of the survey, two surveyors entered the facility through an unlocked front entrance, which activated a loud screeching alarm near the entrance and a beeping sound with visual indicators at the One South nursing station. However, as the surveyors moved further into the building, the alarm became less audible and was not heard at the One East/West nursing station or on the second floor. Staff present in these areas, including a CNA and an RN, confirmed they could not hear the alarm when it was triggered. Interviews with facility leadership and staff, including the Maintenance Director, Facility Administrator, DON, Director of QA, and CIO, confirmed that the alarm system only provided audible and visual notifications at the One South nursing station and did not communicate alerts to other critical care areas. The system was not monitored by a security company, and information about alarm activations was not relayed to other units. The Director of QA acknowledged the need for an alarm system that could notify all critical care areas, particularly beyond the One South nursing station.
Failure to Document and Accurately Perform Narcotic Shift Counts
Penalty
Summary
The facility failed to ensure that at the completion of the narcotic count, both nurses who participated in the counting documented the accurate count at the change of each shift for three of four medication carts reviewed. Observations revealed that during the narcotic count process, nurses did not consistently sign the accountability pages in the narcotic count binders at shift changes. Specifically, multiple count sheets for the medication carts on 1 South, 1 East, and 2 South B were missing numerous required signatures, with some days showing no signatures at all. The facility policy required two licensed nurses to conduct and document a physical inventory of all controlled substances at each shift change, but this was not followed as evidenced by the missing signatures. Additionally, during the observed narcotic count, nurses did not verbalize the names of the drugs or the residents for whom the medications were prescribed, contrary to facility policy. Instead, only the number of medications on each card was announced. Interviews with nursing staff and facility leadership confirmed that the expected process was not being followed, as both the names of the medications and residents should have been verbalized and the count sheets signed by both nurses at each shift change.
Failure to Protect Resident from Abuse by Family Member
Penalty
Summary
A resident with vascular dementia and severe cognitive impairment, as indicated by a BIMS score of 3 out of 15, experienced an incident of physical abuse during a family visit. The resident was involved in an altercation with a family member, during which the family member became frustrated, threw a television remote at the resident, and then struck the resident on the forehead. The incident was observed and reported by facility staff, and the resident confirmed that the family member had hit him. The facility's abuse prevention policy affirms the right of residents to be free from abuse, neglect, or mistreatment and outlines the facility's responsibility to establish a secure environment. Despite this policy, the facility failed to protect the resident from abuse by a family member during a visit. The event was documented in the resident's progress notes, and the incident was confirmed through interviews with staff and review of the resident's medical record.
Unsecured Medications and Unlocked Medication Carts
Penalty
Summary
Medications and biologicals were found unsecured on the second floor south nursing unit. At 5:15 AM, 15 medication cards were observed sitting openly on the nursing station desk with no staff present, while a resident was ambulating nearby. Additionally, two medication carts parked near the station were found unlocked, with drawers containing resident medications accessible and unattended. An LPN confirmed that the medications delivered by the pharmacy at approximately 4:00 AM should have been secured and not left on the desk. The LPN also acknowledged that the medication carts should have been locked when unattended. The Director of Quality Assurance further confirmed that facility policy requires medication carts to be locked when not attended and that medications should not be left unsecured on the desk.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, particularly during the weekend of January 25-26, 2025. Interviews with staff, residents, and family members revealed significant concerns about staffing levels, which led to long wait times for residents needing assistance. The facility's staffing plan indicated a minimum number of staff required, but the actual staffing levels during the weekend in question were below these requirements. This deficiency affected all 43 residents on the first floor, as the facility failed to provide adequate nursing-related services to ensure their safety and well-being. Specific incidents highlighted the impact of the staffing shortage. A resident, identified as R23, reported experiencing long wait times while incontinent, and staff confirmed that the facility was short-staffed during that weekend. Another resident, R30, was left wet for at least 90 minutes, and family members expressed concerns about the lack of attention and supervision provided to R30, who was unsteady and confused. The facility's inability to maintain sufficient staffing levels resulted in delayed responses to call lights and inadequate care for residents, as confirmed by interviews with staff and family members. The facility's management acknowledged the staffing issues, citing a birthday party attended by many off-duty CNAs as a contributing factor to the shortage. Despite efforts to recruit staff for vacant shifts, such as offering bonuses and meals, the facility struggled to fill the gaps. The facility did not use agency staff to address the shortage, and ongoing efforts to hire new staff were noted. However, the deficiency in staffing during the specified weekend remained unaddressed, impacting the quality of care provided to residents.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain a written consent explaining the risks and benefits of psychotropic medications for a resident, identified as R26, who was prescribed multiple psychotropic drugs including Zoloft, Lexapro, Remeron, and Prozac. Despite the facility's policy requiring signed consent prior to administering such medications, no documentation was found in the resident's electronic health record indicating that the activated Health Care Power of Attorney (HCPOA) had signed consents for these medications. The HCPOA confirmed via telephone that they had never signed consents for the use of these psychotropic medications. R26 was admitted with multiple complex medical conditions, including major depressive disorder and generalized anxiety disorder, for which the psychotropic medications were prescribed. The facility's Director of Social Services acknowledged that obtaining consents was primarily the responsibility of the nursing staff, with occasional assistance from social services. However, the surveyor's review revealed that the required consents were missing, and the facility was unable to provide any documentation of a Prozac consent. This deficiency was communicated to the facility's administration, including the Nursing Home Administrator and Director of Nursing, but no further information was provided to address the lack of consent documentation.
Failure to Provide Prior Notice for Room Changes
Penalty
Summary
The facility failed to provide prior written notice to four residents regarding room changes, as required by their policy. Resident 22 was moved to another room without prior notice or a choice of rooms, despite being cognitively intact and having expressed a desire to stay with their roommate. The move was reportedly due to safety concerns, but there was no documentation of the incidents leading to this decision, and the resident was not informed in advance. Resident 28, who is also cognitively intact, was transferred to another room without being given a choice or a documented reason for the move. The resident's bed was reportedly not working, but the Director of Social Services was unaware of the reason for the transfer, indicating a lack of communication and documentation regarding the room change. Residents 29 and 30, both with impaired decision-making abilities and activated Health Care Powers of Attorney (HCPOA), were transferred to new rooms without their HCPOAs being notified. Resident 29's move was due to a bed malfunction, but there was no documentation of notification to the HCPOA. Similarly, there was no documentation of the reason for Resident 30's transfer or notification to their HCPOA. These actions demonstrate a failure to adhere to the facility's policy of providing advance notice and involving residents or their representatives in room change decisions.
Failure to Report Alleged Neglect in a Timely Manner
Penalty
Summary
The facility failed to report an incident of alleged neglect involving a resident, identified as R24, to the State survey agency and the Nursing Home Administrator (NHA) within the required timeframe. R24, who is cognitively intact with a BIMS score of 15, reported to a surveyor that during the third shift, a CNA, identified as CNA-SSS, refused to assist her with using a bedpan despite her request due to diarrhea, and instead instructed her to use her diaper. R24 informed another CNA, identified as CNA-TTT, about the incident, but CNA-TTT did not report the allegation to the NHA or any other authority. The facility's policy mandates that any incident or suspicion of abuse, neglect, or mistreatment must be reported immediately to the administrator or a designated individual. However, when the surveyor inquired about the incident, the NHA was unaware of any such report. The NHA confirmed that staff are expected to report allegations of neglect, and upon learning of the incident from the surveyor, the NHA took steps to investigate and report it to the State Agency. The report highlights a failure in the internal reporting process, as the allegation was not communicated to the NHA or external authorities in a timely manner, as required by the facility's policy.
Failure to Report and Address Allegation of Neglect
Penalty
Summary
The facility failed to ensure the protection of a resident, identified as R24, following an allegation of neglect. On the night of the incident, R24 requested to be placed on a bedpan due to diarrhea, but the CNA on duty, identified as CNA-SSS, instructed R24 to use her diaper instead and left the room without assisting her. R24 reported this incident to another CNA, referred to as CNA-TTT, who apologized but did not report the allegation to the Nursing Home Administrator (NHA) or any other supervisory staff. This inaction allowed CNA-SSS to continue providing care for the remainder of the shift, contrary to the facility's policy that requires immediate removal of staff accused of neglect from resident contact. The facility's policy, titled 'Abuse Prevention Program,' mandates that any employee accused of abuse or neglect be removed from resident contact immediately and not return to work until the investigation is complete. However, this policy was not followed, as CNA-TTT failed to report the incident, and CNA-SSS continued to work with residents. The NHA was unaware of the incident until informed by the surveyor, indicating a breakdown in communication and adherence to the facility's internal investigation procedures. This deficiency highlights a failure in the facility's system to protect residents from potential neglect and ensure timely reporting and investigation of such allegations.
Failure to Implement Comprehensive Care Plan for Resident with Depression
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident identified as R27, who was diagnosed with moderate depression, among other conditions. Despite having a Patient Health Questionnaire (PHQ-9) score of 14, indicating moderate depression, and being prescribed medications such as Doxepin and Trazadone for depression, anxiety, and sleep, R27 did not have a mood/psychosocial needs care plan in place. The facility's policy requires that care plans be comprehensive, person-centered, and include measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. However, R27's care plan lacked specific interventions to address mood and psychosocial issues, despite the resident being treated by a psychologist since admission. The deficiency was identified during a surveyor's review of R27's electronic medical record and interviews with facility staff and the resident. The Social Services Director confirmed responsibility for completing sections of the resident's care plan, including mood and behavior, but acknowledged that the care plan should be updated as needed based on resident preferences. During an interview, R27 expressed feeling sad all the time and did not recall receiving a care plan with outlined goals and interventions. The surveyor shared these concerns with the facility's administration, but no further information was provided at the time.
Deficiencies in ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for two residents, R25 and R27, leading to deficiencies in their care. R25, who has multiple diagnoses including hemiplegia and chronic kidney disease, was not provided with incontinence care for approximately five hours, resulting in a large yellowish-brown urine stain on her sheet. Despite her care plan indicating she should be checked and changed every two to three hours, staff did not adhere to this schedule. Observations by the surveyor confirmed that R25 had not been washed or had her incontinence product changed by 10:02 a.m., despite returning from the hospital at 5:18 a.m. R27, who has diagnoses including Type 2 Diabetes Mellitus and End Stage Renal Disease, did not receive showers as per her preference and schedule. Although R27's MDS indicated that it was important for her to choose between different bathing options, she only received four showers since her admission, with no documentation of refusals or reapproaches for missed showers. The facility's policy required documentation of showers and refusals, but this was not consistently followed, leading to a lack of proper hygiene care for R27. Interviews with staff, including the DON and ADON, revealed inconsistencies in the documentation and execution of care plans for both residents. The facility's failure to adhere to its own policies and procedures for providing necessary care and maintaining documentation resulted in deficiencies in the quality of life and care for R25 and R27. The surveyor's findings highlighted the need for improved adherence to care plans and documentation practices to ensure residents receive the care they require.
Inadequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to ensure the safety of three residents, R15, R23, and R30, by not providing adequate supervision and assistance devices to prevent accidents. R15, who is at high risk for falls, did not have the necessary fall prevention interventions documented on the CNA Kardex. Despite a care plan intervention to keep the bed at transfer height, the bed was found in a low position after a fall on 1/15/2025. The Kardex used by CNAs did not include this critical intervention, leading to a lack of proper fall prevention measures. R23, who requires supervision during meals due to a risk of choking, was observed eating without supervision. The care plan, Kardex, and meal ticket all indicated the need for constant supervision, yet staff failed to follow these instructions. CNA documentation inaccurately recorded R23 as independent with meals for 16 out of 25 days, contradicting the required supervision interventions. R30 experienced an unwitnessed fall with injury on 1/15/2025, but the facility did not conduct a thorough investigation. A family member present at the time of the fall was not interviewed, and no witness statement was collected. The facility's failure to gather complete information and conduct a comprehensive investigation highlights a deficiency in their fall prevention and response procedures.
Failure to Provide Comprehensive Behavioral Health Services
Penalty
Summary
The facility failed to provide comprehensive behavioral health care and services to a resident, identified as R22, who has multiple diagnoses including Vascular Dementia, Major Depressive Disorder, Anxiety Disorder, ADHD, Alcohol Dependence, and Opioid Abuse. Despite significant behavioral changes, the facility did not offer necessary behavioral health services related to R22's substance abuse diagnoses. The facility's policy mandates that residents receive necessary behavioral health care to maintain their highest practicable well-being, but this was not adhered to in R22's case. R22's care plan documented various behavioral issues, including inappropriate phone calls, sexually inappropriate behavior, and mood problems. However, the facility did not update the care plan with new behaviors such as R22 banging their head on the headboard and expressing self-harm intentions. The facility also failed to conduct a root cause analysis of R22's escalating behaviors since November 30, 2024, and did not develop non-pharmacological interventions tailored to R22's needs. The facility's interdisciplinary team did not adequately communicate with R22's psychologist and psychiatrist about the resident's behaviors, nor did they complete an incident report for the self-harm behavior observed on January 17, 2025. The Director of Social Services was unaware of the new behaviors, and the Licensed Practical Nurse who observed the self-harm incident did not inform supervisors or complete necessary assessments. This lack of communication and failure to update care plans and conduct thorough assessments contributed to the deficiency in providing appropriate behavioral health services to R22.
Failure to Follow Medication Disposal and Administration Policies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, identified as R26, by not following proper procedures for handling discontinued medications and ensuring timely administration of scheduled medications. R26 was discharged from the facility with discontinued medications, including Abilify, Prozac, and Zoloft, which were not supposed to be sent home. The facility's policy required that discontinued medications be removed from the medication cart and returned to the pharmacy, but this procedure was not followed. R26, who had a range of medical conditions including hypertensive heart disease, chronic kidney disease, diabetes, and vascular dementia, was cognitively intact and had an activated Health Care Power of Attorney during their stay. Despite the facility's policy that medications should be administered within 60 minutes of the scheduled time, R26's medications were administered late on 22 occasions between November 1 and November 26, 2024. The scheduled administration time was 6:30 AM, but the actual administration times varied significantly, with some doses given as late as 1:51 PM. Interviews with facility staff revealed inconsistencies in understanding the policy for medication administration timing. Some staff believed medications could be administered up to two hours late, while others stated a 30-minute window. The surveyor noted a lack of documentation in R26's medical record regarding the late administration of medications. The facility's failure to adhere to its own policies for medication disposal and administration contributed to the deficiencies identified during the survey.
Failure to Provide Resident with Meal Preferences and Required Dietary Items
Penalty
Summary
The facility failed to provide a resident, identified as R27, with food accommodations and preferences as listed on their meal tickets. On a specific date, R27 did not receive the preferred items for breakfast, including a banana, coffee, hot cereal, water, and Nepro, which were listed on the meal ticket. R27, who is cognitively intact and has multiple diagnoses including Type 2 Diabetes Mellitus and End Stage Renal Disease, expressed that they frequently do not receive meal preferences and have to order food from outside. The resident's physician had ordered Nepro with meals to aid in weight stability and healing, but it was not provided. The Dietary Manager and Registered Dietitian confirmed that R27 did not receive the items listed on the meal ticket. The Dietary Manager explained that CNAs are responsible for placing liquids on trays but are not reading the meal tickets properly. The issue was acknowledged as a problem with both CNAs and Dietary Aides not ensuring that residents receive the correct items. The concern was shared with the Nursing Home Administrator and other facility leaders, but no additional information was provided by the facility at that time.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and PPE usage. During incontinence care for a resident with hemiplegia and other health conditions, staff members did not perform hand hygiene appropriately. One staff member wore two pairs of gloves, and another did not remove gloves or perform hand hygiene after handling soiled items. This was contrary to the facility's policy, which requires hand hygiene after contact with body fluids and removal of gloves. In another instance, the facility's wound nurse did not perform hand hygiene during a wound treatment observation for a resident on enhanced barrier precautions. The nurse placed soiled dressings on a device in the room and left to get a garbage bag without washing hands. Upon returning, the nurse continued the treatment without performing hand hygiene after removing gloves, which is against the facility's infection control policy. Additionally, the Nursing Home Administrator entered a resident's room, who was on isolation for COVID-19, without donning appropriate PPE, including a mask, gown, gloves, and eye protection. The administrator also failed to perform hand hygiene upon exiting the room. This was a direct violation of the facility's COVID-19 infection control guidance, which mandates PPE use and hand hygiene to mitigate the risk of disease transmission.
Failure to Ensure Resident Safety and Proper Investigation of Falls
Penalty
Summary
The facility failed to ensure the safety of several residents, leading to accidents and injuries. One resident, R12, was transferred using a pivot transfer instead of the required Hoyer lift, resulting in a laceration that required 17 stitches. The staff involved did not verify the correct transfer method as per the care plan, and there was a lack of clarity on what caused the injury during the transfer. The facility's investigation did not identify the cause of the injury, and the staff involved were not fully aware of the resident's transfer needs. Another resident, R14, experienced multiple falls that were not thoroughly investigated. The falls occurred over several days, and the care plan was not updated promptly to address the risks. The facility did not collect staff statements or determine when the resident was last observed or toileted before the falls. The lack of timely intervention and investigation into the falls contributed to the ongoing risk of harm to the resident. Similarly, R15 experienced several falls that were not adequately investigated. The facility failed to conduct thorough investigations, including obtaining staff statements and determining the root cause of the falls. The care plan was not revised in a timely manner to address the resident's fall risk. Additionally, the facility did not ensure the proper placement of a Wanderguard bracelet, which could interfere with its function, further compromising the resident's safety.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, particularly in the dining areas and hallways. Observations revealed that the dining areas on the first floor, 2 South, and 2 West were consistently unclean, with dried food debris, stains, and other unsanitary conditions present on tables, floors, and furniture. These conditions persisted despite the presence of residents eating meals in these areas, indicating a lack of timely cleaning and maintenance. Housekeeping staff were not present after dinner to clean the dining areas, leading to residents eating in unclean environments the following morning. Interviews with staff, including housekeeping and CNAs, highlighted a disconnect in responsibilities and communication regarding the cleaning of dining areas. Housekeeping staff reported arriving after residents had already begun eating breakfast, and there was confusion about which department was responsible for cleaning after meals. The Housekeeping Director acknowledged the presence of debris from previous days and indicated that education would be provided to staff, but the issue persisted over multiple days of observation. Additional observations included brown water stains on ceiling tiles in hallways, scattered cereal on a piano and bench, and metal pieces protruding from walls where pictures had been removed. These findings suggest a broader issue with maintenance and cleanliness throughout the facility. Interviews with the Maintenance Director revealed a lack of awareness of these issues, and there was no immediate action taken to address them. The Nursing Home Administrator and Director of Nursing were informed of these deficiencies, but no further information was provided on corrective actions taken.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 711 citations issued within 25 miles in the last 12 months — including the 14 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brookfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Care Age | 1.8 mi | ★★★★★ | 1 | 0 |
| Franciscan Woods | 1.9 mi | ★★★★★ | 26 | 0 |
| Congregational Home, Inc. | 3.8 mi | ★★★★★ | 0 | 0 |
| Aria Of Waukesha | 3.9 mi | ★★★★★ | 19 | 0 |
| Lindengrove New Berlin | 4.3 mi | ★★★★★ | 5 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Aria Of Brookfield.
100% money-back within 48 hours.
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.