Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avina On 32nd during CMS and state inspections, most recent first.
Dietary Manager Lacked Required Food Service Certification: The facility failed to employ a DM with the appropriate competencies and skill set to manage food and nutrition services. DM-G only had a Food Safety for Handlers certificate, which the surveyor confirmed was not a national certification from an accredited certifying body. DM-G stated their prior certificate expired in 2020, they had not started a certified food manager course, and they did not have an associate’s degree in food service or hospitality. The director of operations confirmed no waiver was in place and initially believed the DM had the proper certification.
Inaccurate PBJ Staffing Data Submission: The facility did not ensure accurate mandatory PBJ staffing data were submitted to CMS based on payroll and other verifiable records. Surveyors reviewed the PBJ report for the quarter and found excessively low weekend staffing and a one-star staffing rating. Weekend schedules, nurse postings, and the facility assessment matched, but interviews showed timecard issues could affect PBJ data and that staffing alerts were not fully investigated unless they were considered highly serious.
The facility did not maintain required written abuse, neglect, exploitation, and misappropriation prevention procedures and did not complete BID, DOJ response, and IBIS screening every 4 years for two CNAs. During record review, the surveyor found that the screening documents for CNA-M and CNA-V were older than the required timeframe, and HRD-S could not locate updated background checks for either employee. The concern was shared with the NHA, DON, director of operations, and regional nurse consultant.
Failure to Timely Report Abuse and Resident-to-Resident Altercation: A resident reported that a CNA was rough during care, and staff were aware of the allegation, but it was not reported to the State Survey Agency. In a separate incident, two residents were involved in an aggressive altercation, and although an abuse report was eventually submitted, the surveyor found the facility had documentation showing awareness of the event earlier than the report time.
A resident who was cognitively intact and dependent for toileting hygiene reported that a CNA was rough during pericare and continued care after the resident said it was too rough. The grievance file included only partial statements, did not include a statement from the CNA who first heard the complaint, and did not show interviews of other residents. The DON/NHA also could not determine when the incident occurred, and no FRI was completed for the abuse allegation.
A resident with an ingrown great toenail and recurrent toe infections did not receive timely foot care or podiatry follow-up. The resident’s toenails were observed to be long and unkept, and the record lacked a foot care plan when the problem was identified. Despite repeated recommendations from the NP, Wound MD, and ER physicians, podiatry was delayed for months, and the facility did not consistently carry out ER instructions such as podiatry follow-up and toe soaks. The resident required antibiotics more than once for the infected toe before podiatry was finally completed.
A resident with dementia, schizophrenia, and depression had an Abilify dose that was supposed to be decreased, but the MAR was transcribed incorrectly and the medication was increased instead, with no documented behaviors to justify the higher dose. Another resident with dementia and CKD had Seroquel increased twice and PRN Seroquel and Haldol used beyond the allowed timeframe, but the record showed only baseline wandering/pacing and no specific behavior documentation to support the psychotropic use.
A resident with paraplegia, dementia, and TBI had bed rails used for positioning, but the rails were not included in the care plan, there was no physician order, and no quarterly reassessments were documented. Staff reported the resident could no longer use the rails because of hand contractures, while the DON could not locate an updated assessment, order, or care plan entry for the bed rails.
Inaccurate Daily Nurse Staffing Postings: The facility did not ensure daily nurse staffing postings reflected the actual hours worked by RN, LPN, CNA, and MT staff. Surveyors found multiple discrepancies between staffing schedules and posted hours across several shifts, and the HRD stated postings were calculated using typical shift hours rather than actual hours worked when staff arrived late or left early.
Several residents requested a grievance box and accessible grievance forms to allow for anonymous complaints, but only an unlocked suggestion box was provided and grievance forms were not available at the nurses' station. Staff were unaware of the location of grievance forms, and the facility's grievance policy was locked away, making it inaccessible to residents. This resulted in residents lacking a means to file grievances anonymously or without staff knowledge.
A resident with hemiplegia and intact cognition reported her antenna was stolen from outside her room while she was napping. Another resident witnessed a staff member cut the wires and take the antenna. The incident was reported to the Administrator, but the antenna was not replaced and the investigation was incomplete. The facility failed to report the misappropriation to the state as required by policy.
A resident with cognitive intactness and physical impairment reported that her antenna was stolen from outside her room while she was napping, with another resident witnessing a staff member taking the item. The incident was reported to the Administrator, but the allegation was not reported to state authorities as required, and the investigation file was incomplete. The facility's policy mandates reporting such incidents, but this was not followed.
Thirteen residents experienced misappropriation of their trust funds when a staff member manipulated account transactions for personal gain. The staff member concealed unauthorized withdrawals, making them appear legitimate and bypassing existing oversight procedures. Despite the discrepancies, residents did not report issues accessing their funds, and no negative outcomes were reported during interviews.
The facility failed to ensure a safe environment for residents who smoke or vape, and for a resident requiring assistance during transfers. Thirteen residents were allowed to smoke or vape without proper supervision or safety measures. One resident vaped in her room while using oxygen, posing a fire risk. Another cognitively impaired resident smoked unsupervised outside designated areas. Additionally, a resident was left outside in the cold after smoking, unable to re-enter the building independently. A resident requiring a Hoyer lift was transferred by a CNA without a second staff member, resulting in bilateral femoral fractures.
The facility failed to properly label and date food items, leading to potential food safety issues for 51 residents. Observations revealed expired heavy whipping cream, incorrectly dated food containers, and improperly managed thickened drinks and shakes. The dietary manager was unaware of specific requirements for dating thawed and opened items, resulting in potential risks of food-borne illness.
The facility failed to maintain a safe and homelike environment, with six resident rooms showing various forms of wall damage, including unpainted drywall, holes, and broken areas. Staff, including the NHA and Maintenance Director, were aware of the issues but cited a lack of time to address them. The facility's policy lacked specific procedures for room upkeep.
A resident with severe cognitive impairment was not assessed or authorized for self-administration of medications, contrary to facility policy. Medications were left at the resident's bedside without proper identification or a physician's order, increasing the risk of medication errors. The DON confirmed that the resident could not self-administer medications.
A resident with a history of cystocele repair and a suprapubic catheter was admitted to a facility without an indication for the catheter and without physician orders for catheter care. The care plan did not include the appropriate catheter type, and the catheter bag lacked a privacy cover. Observations and interviews confirmed these deficiencies, indicating a failure to comply with proper catheter care protocols.
Two residents experienced delays in receiving pain medication, with one resident waiting over 30 minutes and another over an hour. The delays were due to staff being occupied with other tasks, leading to increased pain levels for both residents.
A resident with diabetes mellitus received improperly mixed Novolog 70/30 insulin from a Certified Medication Technician (CMT) who was unaware of the need to mix the insulin before administration. The Director of Nursing confirmed the oversight, which could have affected the resident's blood glucose levels.
The facility failed to follow proper infection control practices, leading to potential cross-contamination during care for two residents. CNAs did not wear gowns for a resident with enhanced barrier precautions, and a CNA used the same gloves for multiple tasks during catheter care. An RN did not sanitize a table before a dressing change, and another RN dispensed medications without hand hygiene or gloves, contaminating the tablets.
A resident with pressure ulcers and a leg fracture did not receive proper care due to the facility's failure to update the care plan. The resident's leg brace was not discontinued as ordered, and heel boots for pressure relief were not used. Staff continued to document skin checks under a brace that was no longer worn, and the care plan was not updated to reflect these changes.
Two residents requiring Enhanced Barrier Precautions (EBP) due to wounds and indwelling catheters did not receive appropriate care. Observations showed a lack of signage and personal protective equipment (PPE) near their rooms, and staff did not wear gowns during wound care treatments, violating EBP protocols. The Director of Nursing confirmed the need for EBP, but staff failed to comply.
Dietary Manager Lacked Required Food Service Certification
Penalty
Summary
The facility did not employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services because the Dietary Manager (DM)-G did not have a qualified certificate to manage the kitchen. DM-G provided a certificate of completion for Food Safety for Handlers, and the surveyor confirmed that this was not a national certification for food service management and safety from a national certifying body. DM-G’s hire date was documented as 9/20/2023, and DM-G stated they were working on getting a manager certificate. During interview, DM-G confirmed they had not started a course for a certified food manager credential and stated their previous certificate expired in 2020 and had not been renewed. DM-G denied having an associate’s degree in food service or hospitality and was not aware whether the facility had a waiver in place. When the concern was shared with the NHA, DON, director of operations, and regional nurse consultant, the director of operations confirmed no waiver was in place and initially thought DM-G had the proper certification. The director of operations later provided the same Food Safety for Handlers certificate and acknowledged it was not from an accredited national certifying body.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility did not ensure accurate mandatory submission of PBJ staffing information based on payroll data in a uniform electronic format to CMS for Fiscal Year Quarter 2 2026. The report states that staffing and census data for the quarter were not accurately submitted, and the deficiency was identified during review of the CMS Electronic Staffing Data Submission Payroll-Based Journal requirements, which require complete and accurate direct care staffing information based on payroll and other verifiable and auditable data. Surveyors reviewed the PBJ Staffing Data Report, CASPER Report 1705D, for Quarter 2 2026 and found the facility had excessively low weekend staffing and a one-star staffing rating. They compared weekend schedules, nurse postings, and the facility assessment and found no discrepancies between the schedules and the assessment. During interviews, the HRD stated that scheduling is completed at the facility and that timecard issues can cause PBJ discrepancies, while the director of recruitment stated that timecard data is uploaded into software that generates alerts, but that alerts other than very serious ones were not really investigated. The director of recruitment also stated they were not sure why the facility triggered for one-star staffing and excessively low weekend staffing during the quarter.
Failure to Maintain Required Abuse Prevention Screening Records
Penalty
Summary
The facility did not implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The facility policy titled Abuse, Neglect, and Exploitation stated that it was the facility’s policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property, and that background, reference, and credential checks would be conducted on potential employees, contracted temporary staff, students, volunteers, and consultants. During record review on 6/24/26, the surveyor requested employee files for 8 randomly selected employees from the HRD. The surveyor reviewed the files for CNA-M and CNA-V and found BID forms, DOJ response documents, and IBIS letters that were more than four years old. HRD-S stated the background checks for CNA-M and CNA-V were out of compliance and could not locate updated background checks from the last four years for either employee. HRD-S also clarified that CNA-V had been rehired on 9/1/22 after an original hire date in October 2021. The surveyor discussed the concern with the NHA, DON, director of operations, and regional nurse consultant.
Failure to Timely Report Abuse and Resident-to-Resident Altercation
Penalty
Summary
The facility did not ensure that allegations of abuse and a resident-to-resident altercation were reported to the State Survey Agency within the required timeframe. The report states that the facility policy required alleged violations to be reported to the Administrator, State Agency, and other required agencies immediately, but not later than 2 hours when abuse or serious bodily injury was involved, or not later than 24 hours when abuse was not involved and there was no serious bodily injury. One incident involved R34, who was cognitively intact and required substantial to maximal assistance with toileting hygiene and was always incontinent of bowel and bladder. R34 told staff that CNA-Y was rough during incontinent care and continued cleaning despite R34 saying the care was too rough. R34 later also reported that CNA-Y refused to help with a computer cord because R34 would not allow CNA-Y to provide care anymore. The grievance record and staff statements showed that multiple staff were aware of R34's complaint that CNA-Y was too rough with cares, but the allegation was not reported to the State Survey Agency. A second incident involved R4 and R46. R4 had severe vascular dementia with psychotic disturbance, traumatic brain injury, psychotic disorder with delusions, and anxiety, and had a BIMS score indicating moderate cognitive impairment. R46 had schizoaffective disorder, bipolar disorder, and anxiety, and was cognitively intact. A progress note documented that R46 was observed acting aggressively toward another resident and admitted to punching the other resident in the stomach. Although the facility submitted an abuse report to the State Agency the next day, the surveyor identified that the LPN had documented the aggressive behavior earlier the same day, showing the facility was aware of the incident before the report was made.
Failure to Thoroughly Investigate Allegation of Rough Care
Penalty
Summary
The facility did not thoroughly investigate an allegation that a CNA was rough with a resident during incontinence care. The resident was cognitively intact, required substantial to maximal assistance with toileting hygiene, and was always incontinent of bowel and bladder. The resident reported that CNA-Y was rough while providing pericare, and that when the resident told CNA-Y to stop being too rough, CNA-Y continued the care and said, "I'm sorry, but I need to get you clean." The resident later told facility staff that CNA-Y had been rough during care. The grievance record documented the resident’s complaint that CNA-Y was too rough when cleaning the resident, but the investigation did not include a complete statement about the allegation. The written statement from CNA-Y addressed only a separate issue involving the resident asking for help with a computer cord and did not include the rough care allegation. CNA-Y later confirmed to the surveyor that the resident told CNA-Y they were being rough and that CNA-Y continued cleaning the resident. A statement from an LPN noted the complaint, but the LPN stated the resident did not tell them directly and that the information came from another CNA. The investigation also did not include statements from all involved persons or other residents. The CNA who initially received the report from the resident was no longer employed and was not interviewed, and there was no statement from that CNA in the grievance file. The SW interviewed the resident after being informed by administration, but other residents were not interviewed to determine whether they had concerns about CNAs being rough with care. The surveyor reviewed the facility-reported incidents and found no FRI for the allegation of abuse, and the facility did not determine when the incident occurred. Based on the record review and interviews, the allegation of abuse was not thoroughly investigated.
Failure to Provide Timely Foot Care and Podiatry Follow-Up
Penalty
Summary
The facility did not ensure proper foot care and treatment for a resident with an ingrown right great toenail and repeated toe infections. The resident was admitted with morbid obesity and peripheral vascular disease, was cognitively intact, and required substantial to maximum assistance with bathing and showering. The resident’s record did not contain a foot care plan or toenail care interventions when the ingrown toenail was identified, and survey observation found the resident’s toenails to be long and unkept, with black scabbing along the right great toe. The resident’s ingrown toenail was first documented when staff noted slight bleeding and an order was entered for bacitracin and a podiatry referral. The resident’s NP and Wound MD also documented the ingrown toenail and recommended podiatry. Despite these recommendations, the resident was not seen by podiatry for several months. During that time, the resident developed toe infections and was treated with antibiotics after ER visits. The ER discharge instructions included follow-up with podiatry and, on one occasion, toe soaks in warm water three times daily, but the facility did not enter the podiatry referral or the toe soak order into the record. The resident continued to have recurrent problems with the right great toe, including swelling, tenderness, and infection, and the Wound MD documented that the wound was exacerbated by infection and again recommended podiatry and oral antibiotics. The resident later reported wanting to see podiatry because of elongated toenails. Podiatry was not completed until more than seven months after the first referral, and the podiatrist stated that if the facility had communicated earlier, the resident could have been seen sooner. The podiatrist also stated that antibiotics treated the infection but not the underlying ingrown toenail problem. After podiatry evaluation, the resident’s toe issue resolved.
Unnecessary Psychotropic Medication Use and Inadequate Behavior Documentation
Penalty
Summary
The facility did not ensure residents were free from unnecessary psychotropic or antipsychotic medications for 2 of 5 sampled residents. One resident with diagnoses including vascular dementia, auditory hallucinations, schizophrenia, and major depressive disorder had an Abilify (aripiprazole) dose that was supposed to be decreased, but the order was incorrectly transcribed and the medication was instead increased. The record did not identify specific behaviors to justify the increase, and survey review found the resident continued to receive multiple aripiprazole doses on the MAR, including duplicate entries for the same medication under different names and strengths. For that resident, the psychiatric note documented that staff reported wandering and attempted elopement, but also stated this behavior was typical, the resident accepted redirection easily, and staff denied combativeness or aggression. The surveyor found no evidence of behaviors other than wandering/exit seeking, which staff and the PMHNP described as baseline. The surveyor also noted that the medication order was changed again later, but the record still did not show behaviors supporting the higher dosing that was being administered. The second resident had diagnoses including chronic kidney disease stage 3, senile degeneration of the brain, and dementia, and had been on hospice until 6/30/25. The resident’s quetiapine (Seroquel) was ordered at bedtime and as needed for mood disorder, but the PRN order lacked a stop date and was given multiple times before being discontinued. The scheduled quetiapine dose was increased twice within about 2 months, yet the record did not show behaviors to justify either increase; nursing notes described only occasional wandering or pacing, and the behavior monitoring on the MAR and care plan documentation was generic or showed zero behaviors. Haloperidol PRN was also ordered without a stop date and was administered repeatedly beyond 14 days, with no documented behaviors to support its use.
Bed Rail Use Not Fully Assessed or Documented
Penalty
Summary
The facility did not comprehensively assess the use of bed rails for a resident with paraplegia, profound intellectual disabilities, vascular dementia, and traumatic brain injury. The resident was dependent on staff for eating, hygiene, showering, bed mobility, and transferring, and required substantial assistance for dressing. Although an evaluation on 1/14/26 documented that bed rails were added to assist with bed mobility and that the resident's POA was informed of the risks and benefits and consented, the resident's plan of care and physician orders did not include bed rails, and the resident's quarterly MDS documented that the resident did not have bed rails. Survey review of the electronic health record showed documentation of bed rails in progress notes, but no corresponding care plan entry or physician order. The facility's policy required bed rail assessments at least quarterly, yet the last documented bed rail assessment was the initial evaluation on 1/14/26, with no evidence of quarterly reassessments. Staff interviews indicated that the resident had previously used the bed rails for repositioning, but by the time of survey the resident could no longer use them because of hand contractures and required staff assistance for repositioning. Interviews with nursing staff and leadership showed inconsistent awareness of the resident's current bed rail status and the reassessment process. A CNA stated the resident could not use the bed rails due to hand contractures and had never been seen using them. An LPN and a unit manager stated quarterly reassessments were supposed to occur, but neither knew when the resident's decline occurred or when the last assessment was completed. The DON stated they were unaware of the resident's decline, could not locate an updated bed rail assessment, physician order, or updated care plan, and acknowledged the resident should have been reassessed when the decline occurred.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility did not ensure that the daily nurse staffing information posted for residents, staff, and visitors reflected the actual hours worked by RN, LPN, CNA, and MT staff directly responsible for resident care. Review of weekend staffing schedules and required staffing postings from 1/1/26 through 1/31/26 showed discrepancies on 6 of 9 days reviewed, including mismatches between posted hours and scheduled hours for LPNs, CNAs, RNs, and MTs on multiple shifts. The report also noted additional discrepancies in staffing totals documented on postings reviewed between 5/22/26 and 6/22/26. During interview, the HRD stated they were responsible for completing the daily staffing posting and explained that the hours were calculated by counting staff on the schedule and multiplying by the typical shift hours for each role. The HRD stated they did not calculate actual hours worked when staff left early or arrived late, and acknowledged that the January postings should have reflected actual hours worked. The HRD further stated that, as of the interview, staffing totals were still being calculated using typical shift hours rather than actual hours worked when staff did not work the full shift.
Failure to Provide Accessible Grievance Process for Residents
Penalty
Summary
The facility failed to support residents' rights to voice grievances or complaints without discrimination or reprisal. During a resident group interview, several alert and oriented residents stated that they had requested the installation of a grievance box with attached grievance forms to allow for anonymous submissions. Review of Resident Council minutes confirmed repeated requests for accessible grievance forms and a grievance box, with the administrator initially agreeing to provide these. However, observations revealed that only an unlocked suggestion box was available, not a grievance box, and that the suggestion cards did not serve the same purpose as grievance forms. The facility's grievance policy and procedure were found locked in a glass cabinet, making them inaccessible to residents, and no grievance forms were readily available at the nurses' station as claimed by the administrator. Interviews with staff, including a registered nurse and the social service director, indicated that grievance forms were not present at the nurses' station and staff were unaware of their location. The Resident Council President confirmed ongoing requests for a grievance box and forms, emphasizing that residents should not have to ask staff for these materials. The facility's own grievance policy stated that notices of residents' rights regarding grievances should be posted in prominent locations and that grievance forms should be accessible, but these requirements were not met, resulting in a failure to provide residents with a means to file grievances anonymously or without staff knowledge.
Failure to Prevent and Report Misappropriation of Resident Property
Penalty
Summary
A cognitively intact resident with a diagnosis of flaccid hemiplegia reported that her antenna, which was magnetically mounted outside her room, was stolen while she was napping. Another resident stated that they witnessed a staff member, identified as the Wound Care Nurse/PM Supervisor, cut the wires and take the antenna. The resident reported the missing antenna to the Administrator, who indicated he would replace it, but the antenna was not replaced. The Administrator later discovered that the replacement order had been cancelled by Corporate, and the whereabouts of the original antenna remained unknown. The facility's investigation into the misappropriation of property was incomplete, and the incident was not reported to the State of Wisconsin as required by facility policy. The accused staff member denied involvement, stating they were not present at the facility when the incident occurred. The facility's policy mandates reporting allegations or suspicions of misappropriation to the state survey agency, but this was not followed in this case.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property involving a resident who was cognitively intact and had a diagnosis of flaccid hemiplegia affecting the left nondominant side. The resident reported that an antenna, which was magnetically mounted outside her room, was stolen while she was napping. Another resident witnessed a staff member, identified as the Wound Care Nurse/PM Supervisor, cut the wires and take the antenna. The resident reported the missing antenna to the Administrator, who stated he would replace it, but the antenna was not replaced, and the resident remained without it. Upon review, it was found that the Administrator was informed of the allegation but did not report the incident to the State of Wisconsin as required. The Administrator also acknowledged that the investigation file was incomplete and was unaware that the replacement order for the antenna had been canceled by Corporate until the issue was raised during the complaint survey. The accused staff member denied involvement, stating she was not present at the facility when the incident occurred. The facility's policy requires reporting of suspected abuse, neglect, or misappropriation to state authorities, but this protocol was not followed in this case.
Misappropriation of Resident Trust Funds by Staff Member
Penalty
Summary
The facility failed to protect the belongings and funds of thirteen residents, resulting in misappropriation of resident trust funds by a former Business Office Manager (FBOM). The FBOM was found to have taken monies from the resident trust for personal gain, with discrepancies identified in the accounts of multiple residents. The incident was discovered after suspicions arose regarding unauthorized use of the facility credit card, prompting an internal investigation and audit of the resident trust fund, facility credit card, and petty cash accounts. The audit revealed that the FBOM had manipulated transactions to appear legitimate, making the misappropriation difficult to detect. Interviews with facility leadership confirmed that the FBOM had a clean background check and no prior indications of misconduct. The FBOM was able to conceal the movement of funds and falsify documentation, which allowed the misappropriation to go unnoticed during routine oversight. Despite the discrepancies, residents did not report issues with accessing their funds when requested, and no negative outcomes were voiced by residents during interviews conducted as part of the survey process. A review of facility policies indicated that procedures were in place to safeguard resident funds, including requirements for documentation, witness signatures for disbursements, and monthly transaction reviews. However, these controls were insufficient to prevent the FBOM from accessing and misappropriating resident funds. The deficiency was identified through the facility's own investigation and subsequent audit, which flagged irregularities in the trust accounts of thirteen residents.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for residents who smoke or vape, as well as for a resident requiring assistance during transfers. Thirteen residents were identified as being allowed to smoke or vape without proper supervision or safety measures in place. One resident was observed vaping in her room while using oxygen, which poses a significant fire risk. Another resident, who was severely cognitively impaired, was allowed to smoke unsupervised outside of designated areas without any safety equipment present. Additionally, a resident was left outside in the cold for an extended period because he could not re-enter the building independently after smoking. The facility's policies on smoking and vaping were not adequately enforced, as evidenced by the lack of initial and quarterly smoking assessments for several residents. Care plans for residents who smoked or vaped were not consistently developed or updated to reflect their needs and safety requirements. This lack of oversight and documentation contributed to the unsafe conditions observed by surveyors. Furthermore, a resident who required a Hoyer lift for transfers was moved by a CNA without the assistance of a second staff member, resulting in the resident sustaining bilateral femoral fractures. The CNA admitted to transferring the resident alone, which violated the facility's resident handling policy. This incident highlights the facility's failure to provide adequate supervision and assistance during resident transfers, leading to actual harm.
Removal Plan
- The facility updated their policy and procedure to address safety in using e-cigarettes including their use only in designated smoking areas.
- Assessments were reviewed and updated for all residents known to smoke/vape.
- Care plans were reviewed and updated for all residents known to smoke/vape. Appropriate interventions were put into place to ensure resident safety.
- All staff were trained on the updated policy and procedure and location of the smoking area.
Food Labeling and Dating Deficiency in Facility Kitchen
Penalty
Summary
The facility failed to ensure that food items were properly labeled and dated, leading to potential food safety issues for 51 residents who received meals from the facility kitchen. During an initial kitchen observation, it was found that the walk-in refrigerator contained six one-quart cartons of heavy whipping cream with expired dates. The dietary aide confirmed the expired dates and stated they would be discarded. Additionally, three large plastic containers in the food preparation area had incorrect or uncertain posted dates for breadcrumbs, oatmeal, and rice. The dietary manager could not confirm when these items were placed in the containers. A 25 lb. container of Ready Care Instant Food Thickener was found opened and uncovered, with an old date, and the dietary manager acknowledged it had not been used for a long time and needed to be discarded. Further observations revealed that the walk-in refrigerator contained a box of Ready Care Strawberry Shakes that were thawed but not dated, contrary to instructions to use within 14 days after thawing. The dietary manager was unaware of the requirement to date the shakes when thawed. Additionally, opened cartons of Ready Care Thickened Dairy Drink and Ready Care Thickened Apple Juice were found with dates exceeding the recommended 7-day refrigeration period after opening. The dietary manager was not aware of the special requirements for these thickened drinks and disposed of the opened drinks. These lapses in food labeling and dating practices had the potential to lead to food-borne illness among all facility residents.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe and homelike environment for residents, as evidenced by the condition of six resident rooms across two halls. Observations revealed various forms of wall damage, including unpainted drywall plaster, holes, and broken areas in the walls. In one room, a resident expressed a desire for the unpainted area behind their bed to be painted, indicating a lack of timely maintenance. Additionally, a curtain rod was found to be broken, further contributing to the unsafe and unhomelike conditions. Interviews with staff, including the Nursing Home Administrator and the Maintenance Director, confirmed awareness of the room conditions. The Maintenance Director admitted to receiving notifications about the wall damage but cited a lack of time to address all issues. The facility's policy on maintaining a safe and homelike environment lacked specific procedures for room upkeep, contributing to the ongoing deficiencies in room maintenance.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R3, was properly assessed and authorized for self-administration of medications. R3, who was admitted with a diagnosis of dementia, was found to have a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. Despite this, there was no evidence in R3's medical record of a physician's order for self-administration of medication, nor was there an assessment or care plan in place for self-administration. This oversight was contrary to the facility's policy, which requires an interdisciplinary team assessment and a prescriber's order for residents who wish to self-administer medications. During an initial tour, a medication cup containing various pills was observed on R3's overbed table. R3 was unable to identify the medications or recall who provided them. A Certified Medication Tech (CMT) confirmed that she had given the medications to R3, but they were left on the overbed table, and she could not identify them. The Director of Nursing (DON) confirmed that medications should not be left at a resident's bedside unless the resident is capable of self-administration, which R3 was not. This failure to adhere to the facility's policy increased the potential for medication errors.
Inadequate Catheter Care for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic catheter. The resident, who had a history of cystocele repair and a suprapubic catheter, was admitted to the facility without an indication for the catheter and without physician orders for catheter care. The resident's care plan did not include the appropriate type of catheter, and there was no documented evidence of catheter care as an intervention. Observations revealed that the resident's catheter bag lacked a privacy cover and was positioned in a way that was visible to others. Interviews with the Director of Nursing confirmed the absence of necessary physician orders, an indication for the catheter, and the correct catheter type in the care plan. The DON also confirmed that the catheter bag should have had a privacy cover, which was not initially provided. These deficiencies were identified through observations, interviews, and record reviews, highlighting a lack of compliance with proper catheter care protocols for the resident.
Delayed Pain Management for Two Residents
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents, R42 and R149, as per their care plans and professional standards. R42, who was admitted with conditions including peripheral vascular disease and a surgical wound, reported a pain level of 6.5 out of 10, which she considered unacceptable. Despite requesting pain medication, there was a delay of over 30 minutes before she received it. During this time, R42 was observed moaning and rocking due to pain. The LPN responsible for administering the medication was observed engaging in other tasks and delayed attending to R42's request. R149, who had an abdominal surgical wound, also experienced significant delays in receiving pain medication. She reported pain levels of 8 or 9 out of 10 and had to wait over an hour for her medication after requesting it. The delay was attributed to the assigned nurse, RN J, being tasked with one-on-one supervision duties in another unit, which disrupted her medication pass schedule. As a result, R149's pain level increased to 10 out of 10 before she received her medication. Interviews with the Director of Nursing and other staff confirmed that the delays in administering pain medication were not in line with the facility's policy and expectations. The DON acknowledged the importance of timely pain management and was unaware of the specific delays experienced by R149. The facility's policy emphasized prompt assessment and treatment of pain, which was not adhered to in these cases.
Failure to Properly Mix Insulin Before Administration
Penalty
Summary
The facility failed to ensure that medications were accurately administered to a resident, identified as R9, who was readmitted with a diagnosis of diabetes mellitus. During an observation, a Certified Medication Technician (CMT M) prepared and administered Novolog 70/30 insulin to R9 without mixing it as required. The manufacturer's instructions for Novolog 70/30 insulin specify that the vial should be gently rolled to mix the 70% intermediate-acting insulin with the 30% short-acting insulin before administration. However, CMT M did not perform this step, which could lead to an inaccurate dosage being administered. Interviews conducted with CMT M and the Director of Nursing (DON B) confirmed the oversight. CMT M admitted to not being aware of the need to mix the insulin, despite having been marked as satisfactorily performing insulin administration on her competency checklist. DON B acknowledged that the failure to mix the insulin could have affected R9's blood glucose levels. An interview with a Registered Nurse (RN N) further confirmed the correct procedure for preparing 70/30 insulin, which involves rolling the vial to mix the two types of insulin.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, resulting in potential cross-contamination during care for two residents. Resident R35, who had enhanced barrier precautions due to a previous infection with Providencia Rettgeri, did not receive appropriate care as CNAs F and G provided personal care without wearing gowns, despite being aware of the need for enhanced precautions. Additionally, CNA D, while providing suprapubic catheter care for Resident R100, failed to change gloves after touching various surfaces and carried soiled towels against his uniform, which could have led to contamination. Further deficiencies were observed during a wound dressing change for Resident R100, where RN E did not sanitize the overbed table or use a barrier before placing dressing supplies on it. Additionally, RN N dispensed medications for another resident without performing hand hygiene or wearing gloves, using her fingers to take tablets from bottles, which contaminated the medications. The Director of Nursing confirmed these lapses in infection control procedures, acknowledging the risk of cross-contamination and infection to other residents.
Failure to Update Care Plan and Provide Pressure Relief
Penalty
Summary
The facility failed to ensure that a resident with pressure injuries received the necessary care and treatment to promote healing. The resident was admitted with unstageable pressure ulcers on the left thigh and shin, as well as a leg brace for a fracture. The facility did not update the resident's care plan to reflect the discontinuation of the leg brace as ordered by the orthopedic physician, nor did it include the use of heel boots for pressure relief. The resident's care plan and CNA Kardex were not updated after the orthopedic physician's order to discontinue the leg brace. Despite the order, staff continued to document skin checks under the brace, which the resident was no longer wearing. Additionally, during a wound treatment observation, the resident was not offered heel boots, which were supposed to be used at all times for pressure relief. Interviews with the Wound RN and the Director of Nursing confirmed that the care plan should have been updated to reflect the discontinuation of the leg brace and the use of heel boots. The facility's failure to update the care plan and ensure the use of heel boots resulted in inadequate care for the resident's pressure ulcers.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, R1 and R2, as recommended by the CDC and per the facility's policy. R1 was admitted with multiple diagnoses, including unstageable pressure ulcers and an indwelling catheter, which required EBP. However, observations revealed that there was no sign posted on R1's door to indicate the need for EBP, and there were no gloves or gowns available near the room. During wound care treatment, the staff did not wear gowns, violating the EBP protocol. Similarly, R2, who had severe cognitive impairment and multiple wounds, including an unstageable pressure ulcer and an indwelling catheter, also required EBP. Observations showed that there were no indications of EBP in R2's room. During wound care treatment, the staff used gloves and hand hygiene but did not wear gowns, failing to adhere to the EBP guidelines. Interviews with the Director of Nursing confirmed that both residents should have been on EBP due to their conditions. Despite being aware of the policy, the staff did not follow the required precautions, and no additional information was provided to explain the non-compliance.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 390 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kenosha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sheridan Health And Rehabilitation Center | 1.1 mi | ★★★★★ | 33 | 0 |
| Clairidge House | 2.4 mi | ★★★★★ | 29 | 0 |
| Avina Of Kenosha | 3.7 mi | ★★★★★ | 1 | 0 |
| Brookside Care Center | 3.7 mi | ★★★★★ | 9 | 0 |
| Waters Edge Health And Rehabilitation Center | 4.2 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.