Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Barron Care And Rehabilitation during CMS and state inspections, most recent first.
The facility did not complete annual performance reviews and did not provide required in-service education based on those reviews for 6 of 6 CNAs reviewed. Surveyors found that multiple CNAs had performance reviews documented, but there was no documentation of related training. The DON stated the training had not been done and that the facility did not have a PIP in place.
Failure to Complete Required CNA In-Service Training: The facility did not complete the required annual 12 hours of in-service training for 6 of 6 CNAs reviewed. Record review showed no documentation of the required annual training for the sampled CNAs, and the DON stated that only random nursing care topics were discussed at monthly staff meetings. The DON also confirmed that dementia education had last been completed previously and that no PIP was in place.
The facility failed to follow infection control practices during resident care. A CNA handled used water cups and entered multiple residents' rooms during water pass without performing hand hygiene between rooms, an RN assisted with wound care for a resident on contact precautions without wearing a gown, and an LPN administered eye drops to a resident without gloves. Staff interviews showed misunderstanding of hand hygiene and PPE expectations.
A resident with dementia and wandering behaviors eloped after staff failed to promptly respond to a wander guard alarm, and the record did not support consistent 1:1 supervision. The facility also did not update a resident’s care plan after a fall with injury, had no revised fall interventions noted for another resident with a fall history, and did not document proper Hoyer sling sizing for a dependent resident with severe cognitive and physical impairment.
A resident with dementia, moderately impaired cognition, and documented wandering and elopement risk had a care plan that included one-on-one supervision, structured activities, and a wander guard device. On one occasion, the wander guard alarm sounded as the resident exited the building, but staff did not respond promptly, and the resident was found outside the front entrance in a wheelchair. Although the incident involved potential neglect due to lack of supervision, the DON initially decided it was not reportable, and the administrator did not submit the required abuse/neglect report to the State Survey Agency within the mandated timeframe or complete the misconduct incident report within five business days, resulting in delayed reporting of the alleged violation.
A resident with severe dementia, dependence in all ADLs, and documented BUE ROM issues developed bruising to the left arm and breast and was later found in the ER to have an anterior left shoulder dislocation. Staff reported no falls or equipment malfunctions, and the RN initially noted only a small bruise and was unsure if he fully documented its size and location. Nursing weekly assessments repeatedly documented no contractures, while therapy records showed significant upper extremity contractures and spasticity affecting dressing and bathing. The DON told police and surveyors that the facility could not determine how the injury occurred, yet the facility assumed it was related to improper upper body dressing technique despite lacking documentation of upper extremity contractures and including only a vague disciplinary form for a CNA who had transferred the resident alone with a Hoyer lift.
Two residents receiving psychotropic medications had inadequate behavior monitoring. One resident with dementia, anxiety, depression, wandering, and aggression had TAR entries that did not match progress notes and often lacked the required behavior codes, while another resident with Alzheimer’s disease and anxiety had scheduled clonazepam and PRN lorazepam given with little or no documented target behaviors, including vague “Other” entries without explanation.
Baseline care plans for two residents did not include key information needed to address immediate needs after admission. One resident with a broken humerus and immobilizer lacked weight-bearing status, immobilizer instructions, and skin monitoring guidance, while another resident with acute and chronic pain did not have pain monitoring or intervention details in the initial care plan. Staff interviews showed uncertainty about the immobilizer orders, and the DON stated the pain and immobilizer information should have been included in the baseline care plans.
A resident with Alzheimer’s disease, severe cognitive impairment, and a history of falls had a witnessed fall in her room and was sent to the ER after staff noted pain and a possible leg-length change. Surveyor review found the care plan was not revised after the fall to reflect the resident’s current needs or add new or modified fall-prevention interventions, and the DON had no additional statement.
A resident with severely impaired cognition and a decline in transfer ability did not receive the necessary therapy evaluation after staff identified the change. The resident's MDS showed the need for assistance with all transfers, the care plan listed A2 with an EZ stand, and staff were observed using a mechanical sit-to-stand lift because of weakness. The DON stated the therapy referral had been discussed but was never obtained until later.
A resident admitted with a right humerus fracture was observed wearing a shoulder immobilizer, but the chart lacked orders for the immobilizer, WB status, brace care, or related skin care, and the DON acknowledged the hospital AVS and discharge summary did not include those details. Another resident with dementia and contractures had orders to wear a left shoulder immobilizer and have skin checked under it twice daily, yet no skin checks were documented under the device. In a separate case, a resident with Alzheimer’s disease developed a new open area on the buttock, but staff did not document provider notification or a treatment order for the new skin issue.
Failure to Prevent Device-Related PI: A resident with vascular disease, weakness, and prior wounds developed a stage 2 wound on the top of the foot after wearing a post-op shoe and a stage 2 buttock/sacral wound linked to a Hoyer sling with a toileting hole. The facility had no documented daily skin checks for the foot device, no documented shoe-fit evaluation, and no care plan or order updates for the sling-related injury. Staff were observed continuing to use and leave the wrong sling under the resident, and nursing staff were not documenting daily skin assessments for the wounds.
A resident who self-catheterized for urinary retention did so without a documented facility assessment of need or regular bladder monitoring. Staff had no urology evaluation on file, did not use bladder scans, and did not document urine characteristics or how often the resident actually catheterized. The resident developed recurrent UTIs, and the provider noted infrequent self-catheterization with large retained volumes and symptoms such as foul-smelling, thick urine and stinging.
A resident with a humerus fracture and chronic pain was not consistently provided ordered pain management interventions. The resident reported near-constant pain, worse at night, and said staff did not offer alternatives such as cold packs, massage, conversation, or repositioning. Records showed ordered non-pharmacologic interventions were not documented for extended periods, pain assessments were incomplete, and the DON acknowledged pain should have been consistently assessed and nursing interventions documented.
A resident with CKD and dependence on renal dialysis did not receive required post-dialysis VS on two occasions, and the care plan failed to address the resident’s PICC line. Staff reported confusion about the resident’s access type, the RN was not aware of documentation for PICC site monitoring, and the DON verified the missed VS and inadequate care plan interventions.
A facility medication pass resulted in an 11.54% error rate, with an LPN giving a resident the wrong dose of artificial tears and citalopram and giving another resident the wrong calcium medication. The facility policy required nurses to follow the seven rights of medication administration, and staff interviews confirmed expectations to verify the MAR and medication card and to wear gloves for tasks such as eye drops.
Two residents in a LTC facility developed or worsened pressure injuries due to inadequate care and documentation. One resident, initially admitted without skin impairments, developed a stage 3 pressure injury that progressed to stage 4 due to insufficient assessments and interventions. Another resident had multiple pressure injuries upon admission, but the facility failed to document them accurately or implement consistent repositioning as per the care plan. The interim DON acknowledged the deficiencies and initiated a facility-wide skin sweep and PIP.
The facility failed to provide written notification of transfer or discharge reasons to residents or their legal representatives for five residents. Despite the facility's policy requiring such notices, interviews and record reviews revealed that no written notices were given for transfers to hospitals due to medical conditions. Staff interviews indicated confusion over responsibility for issuing these notices.
The facility failed to provide written bed hold notices to residents or their representatives during transfers to hospitals, affecting five residents. Despite policy requirements, no notices were given, and staff interviews revealed confusion over responsibility for issuing these notices.
Surveyors observed CNAs using clothing protectors to wipe residents' mouths instead of napkins during meal assistance, affecting three residents with cognitive impairments and physical limitations. Despite the availability of napkins, this practice continued, contradicting the facility's policy on maintaining resident dignity.
A resident with multiple health issues, including cognitive impairment and total dependency on staff, was repeatedly observed without access to a call light, preventing them from requesting assistance. Despite the resident's visible discomfort and attempts to call for help, staff failed to ensure the call light was within reach, contrary to facility expectations.
The facility failed to develop comprehensive care plans for two residents, one with hemiplegia and another with severe cognitive impairment, leading to deficiencies in maintaining their baseline ADLs. The care plans lacked necessary updates and interventions, such as a restorative range of motion program and addressing personal preferences for ADL assistance.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident with severe cognitive impairment and multiple medical conditions had a fall intervention not included in their care plan, and their incontinence care plan was not updated after a change in mobility status. Another resident with moderate cognitive impairment and total dependence for ADLs had an outdated care plan that did not reflect their current needs, including the use of a Hoyer lift for transfers.
A resident with severe cognitive impairment and incontinence was not provided necessary toileting and hygiene care. Observations showed the resident was left in a chair for extended periods without being taken for incontinence care, and staff confirmed the resident was only toileted in the morning. The Interim DON acknowledged the need for toileting before and after meals.
A resident with hemiplegia and hemiparesis following a stroke did not receive the recommended restorative range of motion program after being discharged from PT and OT. Despite recommendations, the program was not implemented, leading to a decline in mobility and ADL functions. Staff interviews revealed a lack of awareness and implementation of the program, and the restorative program book did not include the resident's information.
A facility failed to ensure proper labeling of insulin pen medications, leading to a discrepancy between the label and the physician's order for a resident with diabetes mellitus II. The insulin pen was labeled with a fixed dose, while the order required a sliding scale dosage. The RN confirmed the error, and the DON acknowledged that the facility's policy for verifying medication labels was not followed, as the error was not corrected upon receipt, nor was the pharmacy notified.
The facility failed to maintain proper infection control practices as CNAs did not perform hand hygiene between glove changes while providing care to two residents. Despite the facility's policy requiring hand hygiene before and after glove use, CNAs were observed neglecting this practice during morning and catheter care, compromising infection prevention efforts.
Missing CNA Annual Performance Reviews and In-Service Training
Penalty
Summary
The facility did not complete a performance review of every nurse aide at least every 12 months and did not provide 12 hours of regular in-service education based on the outcome of performance reviews for 6 of 6 CNAs reviewed. On 01/06/26, surveyors reviewed CNA records and found that CNA D, CNA K, CNA L, CNA M, CNA N, and CNA O each had an annual performance review documented, but there was no documentation of in-service education based on the performance review for any of them. During an interview on 01/06/26 at 3:12 PM, the DON stated she did not have any documentation for training because it had not been done, acknowledged the concern, and stated she would be working on it. When asked whether the facility had a Performance Improvement Plan in place to resolve the issue, the DON stated no.
Failure to Complete Required CNA In-Service Training
Penalty
Summary
The facility did not complete the required annual 12 hours of in-service training for 6 of 6 CNAs reviewed. Record review showed CNA D, CNA K, CNA L, CNA M, CNA N, and CNA O each had no documentation of the required annual 12 hours of in-service training. During an interview on 01/06/26 at 3:12 PM, the DON stated that this training had not been completed for any CNAs other than random nursing care topics discussed at monthly staff meetings. When asked about annual dementia training, the DON provided education last completed on 09/26/24 and stated that she knew it needed to be completed annually. The DON also stated that there was no Performance Improvement Plan in place documenting a plan to fix the issue.
Infection Prevention and Control Failures During Resident Care
Penalty
Summary
The facility did not provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. During water pass, a CNA exited R35's room carrying an almost empty water cup by the handle with bare hands, placed it on the cart, and then entered R18's room with a new water cup without performing hand hygiene. The CNA repeated this pattern after leaving R18's room and again before entering R16's and R46's rooms, handling used water cups and clean cups without hand hygiene between resident rooms. When interviewed, the CNA stated hand hygiene was done after completing that hall and said her hands get cracked from hand sanitizer and she was unaware it should be used after touching contaminated surfaces such as residents' used water cups. The facility also did not ensure appropriate PPE was used during resident care. During wound care for R34, whose door sign indicated contact precautions, an RN assisted with gathering supplies, applying skin prep, and applying dressings to open skin areas without wearing a gown. The RN stated she did not wear a gown because she was not at risk for splashing, and the DON stated this was a misunderstanding, explaining that a gown was only thought to be needed if there was a risk for splashing. In addition, an LPN administered artificial tears to R21's eyes without wearing gloves. Interviews with other nursing staff and the DON reflected that gloves were expected for eye drops and other tasks involving potential contact with hazardous materials or insertion into the body.
Inadequate supervision and fall prevention interventions
Penalty
Summary
The facility did not ensure adequate supervision and assistance to prevent accidents for residents reviewed for falls and elopement risk. R7, who had dementia with behavioral disturbance, impaired cognition, and wandering/exit-seeking behaviors, was identified as being at significant risk for elopement and had a care plan that included wander guard use and one-on-one supervision. On 10/05/25, R7’s wander guard alarm sounded, but staff did not immediately respond, and R7 eloped from the facility. Staff later found R7 outside the front doors sitting in a wheelchair. The facility’s own report stated the alarm worked properly, but staff did not respond because they did not hear it or were busy preparing for breakfast. The record did not support that R7 received the level of supervision documented in the care plan. After the elopement, a progress note directed CNAs to increase monitoring, but the surveyor found no documentation showing that increased supervision, 15-minute checks, or one-on-one supervision was consistently implemented from the time of the incident. Progress notes later continued to describe wandering and exit-seeking, including statements that R7 required increased supervision on multiple shifts, but the documentation did not support daily or every-shift behavior charting or consistent one-on-one supervision. Staff interviews also reflected that R7 was not always on one-on-one supervision and that the alarm was hard to hear. The facility also failed to update care plans after accidents for other residents. R10, who had Alzheimer’s disease, severe cognitive impairment, wheelchair use, and required staff assistance with transfers, sustained a witnessed fall in her room on 06/15/25 and was sent to the hospital after reporting pain and a shortened leg. The surveyor found that R10’s care plan was not updated after the fall to reflect new interventions. R5, who had Alzheimer’s disease with late onset, dementia with anxiety, oxygen dependence, anticoagulant use, atrial fibrillation, weakness, impaired mobility, and a history of a fall with major injury, also had no revised fall interventions noted after the last documented care plan revision. In addition, R26, who had severe vascular dementia, multiple contractures, and was dependent for all ADLs, was transferred with a Hoyer lift using a sling with black handles, but the record did not identify the correct sling size or document measurements or other assessment to support proper sling selection.
Failure to Timely Report Elopement and Potential Neglect Incident
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged violation involving potential neglect related to a resident elopement, as required by regulation and facility policy. A resident with dementia and moderately impaired cognition, confirmed by a BIMS score of 8/15, had documented wandering behaviors and was assessed as being at significant risk of getting to a potentially dangerous place. The resident’s care plan identified them as an elopement risk with a history of wandering and exit-seeking behaviors and impaired safety awareness, and included interventions such as one-on-one supervision, structured and meaningful activities, and use of a wander guard device on the left wrist with checks for placement every shift and function checks daily. On the date of the incident, the resident’s wander guard alarm activated when the resident exited the building, but staff did not respond to the alarm in a timely manner. The facility’s own elopement policy stated that alarms are not a replacement for necessary supervision and that staff are to be vigilant in responding to alarms promptly, and that adequate supervision will be provided to help prevent accidents or elopements. A CNA later reported hearing the alarm but stated the alarms are hard to hear and that she responded as soon as she could; by the time she responded, the resident had already eloped from the building and was found outside the front doors on the sidewalk, sitting in a wheelchair and stating they were getting some fresh air. The resident was brought back inside and had no injuries, and staff reported the incident to the DON. Despite the elopement and the resident’s known elopement risk, the DON reviewed the elopement policy on the day of the incident and initially determined the event was not reportable because the resident did not leave the property. The incident was not reported to the State Survey Agency within two hours, even though it involved potential neglect related to lack of supervision. The administrator later determined the incident was reportable due to lack of supervision and submitted an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse report the following day, outside the required timeframe. In addition, the misconduct incident report required within five business days of discovery was not successfully submitted within that timeframe, and the administrator did not use the available email system when experiencing difficulty with the electronic reporting system, resulting in further delay in required reporting.
Failure to Thoroughly Investigate Injury of Unknown Origin and Inconsistent Documentation of Contractures
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an injury of unknown origin for one resident with severe cognitive impairment and extensive physical limitations. The resident had vascular dementia with anxiety, Alzheimer’s disease, fibromyalgia, weakness, and multiple lower extremity contractures, and was dependent for all ADLs with transfers requiring a Hoyer lift and two-person assist. The care plan did not specify sling size for Hoyer transfers. The most recent MDS indicated the resident was rarely/never understood and had upper and lower extremity ROM impairments, while multiple weekly nursing skin/condition assessments documented no contractures present. Therapy records, however, showed the resident had significant BUE contracture and ROM issues that affected bathing and dressing, with documented spasticity and tone differences. On the date of the incident, nursing staff were notified of bruising on the resident’s left arm and left breast, along with pallor and poor oral intake. The RN assessed what he described as a small bruise on the back of the arm, reported it to the DON, and was instructed to monitor for worsening, but he was unsure if he documented the size and exact location. The CNA on duty that morning reported she did not look at the resident’s upper body, did not observe bruising, and only reported that the resident appeared different and pale. There were no reports of falls or equipment malfunction, and staff interviews did not identify a clear cause of injury. Subsequent evaluation in the ER identified an anterior left shoulder dislocation with associated ecchymosis, and the ER physician expressed concern for possible abuse or neglect given the resident’s non-ambulatory status and lack of reported falls. During the facility’s internal review, the DON stated that the facility could not determine how the resident sustained the dislocated shoulder and bruising and acknowledged there was no documented explanation for the injury. The DON reported that the facility ultimately assumed the cause was improper upper body dressing technique related to contractures, based on the ER note suggesting this as a possibility and the absence of reported falls or equipment misuse. However, the DON was unable to produce nursing documentation supporting the presence of upper extremity contractures prior to the incident and was unaware that nursing assessments repeatedly documented no contractures. A disciplinary form for a CNA who admitted to transferring the resident alone with a Hoyer lift, despite a two-person requirement, was included in the investigation file, but the form did not identify the resident or provide details of the event. The police report documented that the DON told law enforcement the facility was not able to figure out how the resident obtained the dislocation and bruising, and no further information from external agencies was available in the facility’s investigation file.
Inadequate Monitoring of Psychotropic Medication Behaviors
Penalty
Summary
The facility failed to ensure two residents were free from unnecessary psychotropic medication use by not accurately monitoring resident-specific targeted behaviors for psychotropic medications. The deficiency was identified for R7 and R5 after record review and interview showed that behavior monitoring documented on the TAR did not match the behaviors described in progress notes or, in some instances, did not include the required behavior details at all. R7 was admitted with diagnoses including dementia with behavioral disturbance, depression, and anxiety, and had severely impaired cognition on MDS assessment. R7’s care plan identified target behaviors such as pacing, verbally and physically abusive behaviors, and wandering/exit seeking. R7 received multiple psychotropic medications over time, including olanzapine, escitalopram, fluoxetine, Rexulti, Depakote Sprinkles, and Celexa. The TAR for October, November, and December showed daily check marks for anti-anxiety monitoring without the corresponding behavior numbers, and antidepressant monitoring entries often showed no behaviors or entries that did not align with the progress notes. Progress notes documented behaviors such as elopement, setting off alarms, swearing, crying, yelling, verbal aggression, physical aggression, wandering, and exit seeking. The DON was interviewed and could not provide additional documentation showing the behaviors were being tracked and monitored to determine whether the medications were appropriate and effective. R5 had diagnoses of Alzheimer’s disease and dementia with anxiety and was prescribed scheduled clonazepam and PRN lorazepam for anxiety and terminal agitation. The care plan directed monitoring and documentation of side effects and effectiveness, and the TAR required anti-anxiety target behavior documentation every shift. Review of the TAR and MAR from November through early January showed scheduled clonazepam was administered as ordered and multiple PRN lorazepam doses were given, but behavior documentation was sparse or absent. When behaviors were recorded, they were limited to restlessness or an unspecified “Other” entry without explanation, and many dates showed no behavior documentation despite PRN use. For the final reviewed period, no behaviors were documented at all.
Baseline Care Plans Missing Immediate Needs Information
Penalty
Summary
The facility did not ensure that baseline care plans contained the minimum information needed to meet residents’ immediate needs within 48 hours of admission for 2 residents. For one resident admitted with a right broken humerus and an immobilizer to the right upper extremity, the baseline care plan did not include non-weight bearing status, immobilizer use or care, or skin monitoring related to wearing the immobilizer. Hospital therapy notes stated the resident was to be non-weight bearing to the right upper extremity and to wear the shoulder immobilizer at all times, and the resident stated the immobilizer was to stay on all the time. During interviews, CNA and LPN staff described the immobilizer as a brace used to support the resident’s shoulder and said it was removed for care and then replaced, but they were not able to identify the purpose or instructions from the care plan. The DON stated the orders for the immobilizer and weight-bearing status had not been included on the after-visit summary upon admission, that nursing staff should have clarified the use of the immobilizer and weight-bearing status and added them to the care plan, and that weekly skin checks on bathing days were being done but should have been more frequent and included in the care plan. For another resident admitted with a left humerus fracture, low back pain, chronic pain syndrome, and unspecified pain, the baseline care plan did not include pain monitoring and interventions. The resident had orders for PRN hydrocodone-acetaminophen and non-pharmacologic interventions before PRN pain medication, and the medication was given daily for several days, but pain assessments were only documented on 2 days and showed pain levels of 7. The resident later reported almost constant pain, that staff did not offer alternative methods such as cold packs, conversation, or massage, and that staff did not come in to reposition the resident at night. The pain focus was not added to the care plan until 12 days after admission, and the DON stated the expectation was to have the resident’s pain and interventions in the initial baseline care plan.
Care Plan Not Revised After Resident Fall
Penalty
Summary
The facility did not ensure care plans were revised to reflect residents’ current needs and to provide direction to staff after a status change. R10 was admitted with Alzheimer’s disease and a history of falls, and the 05/02/25 MDS showed a BIMS score of 6/10, indicating severely impaired cognition. R10 used a wheelchair for mobility and required staff assistance with all transfers. The care plan included multiple fall-related interventions, including pressure alarms in the wheelchair and recliner, auto locks on the wheelchair, a Dycem cushion, safe environment measures, reminders to use assistive devices, and other fall-prevention interventions. On 06/15/25, R10 had a witnessed fall in her room. Nursing documentation stated the nurse found the resident and CNA tangled up on the floor, the resident complained of pain, her left leg appeared shorter than the right, and she was sent to the hospital by ambulance after the POA was notified. The resident was evaluated in the ER and determined to have no injuries. Surveyor review found R10’s care plan was not updated after the fall to reflect the event or to add new or modified interventions, and the DON did not provide additional statements when interviewed about the missing update.
Failure to Obtain Therapy Evaluation After Decline in Transfer Status
Penalty
Summary
The facility did not ensure that one resident with a decline in transfer status received the necessary services to carry out ADLs. R7 had severely impaired cognition, with an MDS BIMS score of 04/15, and the MDS showed the resident required assistance with all transfers. The care plan identified ADL self-care deficits related to altered functional abilities, altered cognition, dementia with behaviors, and low back pain, and listed transfer assistance as A2 with an EZ stand. On 12/11/25, the IDT documented that staff had been using A2 with an EZ stand because the resident's transfer status had changed, and the team discussed requesting PT/OT orders to address the decline in functional abilities. During the survey period, staff were observed assisting R7 with transfers using a mechanical sit-to-stand lift, and a CNA confirmed the resident was being transferred with more assistance because of weakness. The DON stated she did not know about a therapy referral after the change in transfer status and later provided a signed physician order for a therapy evaluation dated 01/07/26, stating, "I just got the order today. We discussed it but never got it."
Failure to Enter Orders, Notify Provider, and Monitor Skin Under Immobilizers
Penalty
Summary
The facility did not ensure that a resident admitted with a right humerus fracture and shoulder immobilizer had provider orders entered for the immobilizer, weight-bearing status, brace care, or skin care related to the device. The resident was observed wearing the immobilizer around the chest with arm straps to the right arm, and the medical record contained hospital therapy and orthopedic notes stating the resident was non-weight bearing to the right upper extremity and was to wear the immobilizer at all times. However, the facility record did not contain corresponding orders, and the care plan did not include the immobilizer or skin impairment prevention interventions related to it. Surveyor interviews with HUC staff and the DON showed the facility relied on the hospital AVS for appointments and admission information, and the DON acknowledged that the AVS and discharge summary did not include orders for the follow-up appointment, immobilizer, or weight-bearing status. The DON stated those orders should have been clarified on admission. The DON also stated there was no daily skin assessment in place for the resident and that previous orders were not added to the care plan. The facility also did not implement skin assessment interventions for a resident with severe dementia, multiple contractures, and an immobilizer to the left shoulder. The resident’s care plan and orders included wearing the immobilizer at all times except for hygiene and monitoring skin under the device twice daily, but the record contained no documentation of skin assessment under the immobilizer between the reviewed dates. An RN stated staff only removed the immobilizer and assessed skin if CNAs reported a concern or if it was assigned in the TAR, and the DON stated the skin should be assessed at least once daily under the device. In a separate case, a resident with Alzheimer’s disease and severely impaired cognition developed a new open area to the right buttock, but the record did not show provider notification or a treatment order for the new skin concern.
Failure to Prevent Device-Related Pressure Injuries
Penalty
Summary
The facility did not provide care consistent with professional standards to prevent pressure injuries for one resident who had multiple wound and mobility-related risk factors. The resident was admitted with diagnoses including peripheral vascular disease, venous insufficiency, muscle weakness, difficulty walking, and a history of pressure injury and toe amputation. The resident’s assessments showed existing skin issues, including a stage 2 pressure injury on the left shin present on admission, and later a Braden score of 18 indicating risk for pressure injury development. The resident also had a post-operative shoe after left great toe amputation, but the facility did not have orders or documentation for daily skin assessments of the left foot while the device was in use. The resident developed a new stage 2 pressure injury on the top of the left foot after wearing the post-operative shoe. The record and interviews indicated the wound was discovered after wraps were discontinued, and the root cause analysis identified that there was nothing between the resident’s skin and the boot. The facility documented an order to discontinue the post-surgical shoe and to check skin under removable devices every shift, but there was no documentation of prior daily skin checks, no documented evaluation of the shoe fit, and no documented care plan update addressing the device-related injury before the wound developed. The resident also developed a wound to the sacral/buttock area that was initially documented as moisture associated skin damage and later changed to trauma/injury believed to be caused by shearing from the Hoyer sling. The DON stated the wrong sling with a hole for toileting had been used and that the correct flat sling should have been used, but there was no documentation that staff were educated on the correct sling use, and the intervention was not documented in the care plan, CNA Kardex, or orders. Survey observations showed the sling with the hole remained under the resident while seated in the wheelchair, and staff continued to use that sling during transfers. The resident stated the sling was uncomfortable and that the hem around the hole rubbed the buttock area. Nursing staff also reported they were not documenting daily skin assessments for the wounds, stating the wound provider assessed them weekly.
Failure to Assess and Monitor Intermittent Catheterization
Penalty
Summary
The facility did not ensure appropriate care and treatment for a resident who used intermittent self-catheterization. The resident was admitted with benign prostatic hyperplasia with lower urinary tract symptoms and urinary retention, had intact cognition, no upper extremity impairment, and was dependent for toileting hygiene. His care plan stated that he required intermittent straight catheterization and would do it himself, but the record did not show a urology consult or any documented urologist assessment supporting the need for catheterization after admission. The resident completed self-catheterization without a documented facility assessment of his ability to perform the procedure before 12/03/25. Survey review found no bladder assessments documenting how often he actually catheterized, no bladder scanning results, no bladder training program, and no documentation of urine characteristics. Staff interviews showed the CNA only tracked output and did not report urine color, odor, or consistency to nursing. The RN stated bladder assessments were only done if assigned in the TAR and that the facility did not use a bladder scanner for this resident. The DON stated there was no evaluation from urology, no assessment before 12/03/25 of the resident’s capability to self-catheterize, and no regular bladder assessments. The resident developed UTIs on 12/02/25 and 12/31/25. Provider notes documented recurrent UTI symptoms, including stinging during urination, thick urine, foul-smelling urine, and catheterization volumes of 950 to 1200 mL twice daily without urinating between catheterizations. The provider assessed the recurrent UTIs as likely related to infrequent self-catheterization and increased retention, and increased catheterization to three times daily. During interview, the resident stated he had not seen a urologist since admission, had not had a bladder training program, and had not had bladder scanning to assess retained urine. The DON stated the order for self-catheterization three times daily was based on what the resident reported he was doing.
Inconsistent Pain Assessment and Non-Pharmacologic Pain Interventions
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with acute and chronic pain. R6 was admitted with a fractured upper left humerus and also had chronic pain related to kyphosis and a history of spinal fractures. The resident’s care plan and orders included non-pharmacologic pain interventions such as repositioning, warm or cold packs, massage, distraction, dimmed lighting, music, television, 1:1 communication, and education, to be used before or with PRN pain medication. R6 was cognitively intact and reported almost constant pain, including pain on the left side involving the shoulder, arm, and entire leg, with pain worse at night because the resident could not reposition independently and staff did not come in to reposition them. Record review showed non-pharmacologic interventions were not offered consistently, with no documented interventions from 12/4/25 through 12/25/25 and additional missed dates afterward. The medication record showed Hydrocodone-Acetaminophen was given daily for several days, but pain assessments were documented only twice during that period and both were rated 7/10. After the medication changed to Oxycodone, pain assessments were not completed every shift, and when documented the pain ranged from 0 to 10. During the survey, staff were not observed offering non-pharmacologic interventions, and the DON stated the expectation was that pain would be consistently assessed and nursing interventions documented, which was not done.
Dialysis Monitoring and Access Care Not Provided
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for a resident with chronic kidney disease stage 4 and dependence on renal dialysis who was transported off site for hemodialysis on Mondays, Wednesdays, and Fridays. The resident’s orders required a full set of vital signs and weight after dialysis on those days, but post-dialysis vital signs were not taken after two treatments. The resident’s care plan stated the goal of having no signs or symptoms of complications from dialysis, and the interventions included monitoring the access site for bruit and thrill, bleeding, and signs or symptoms of infection. The resident reported that staff had not looked at the PICC line since admission, and the medical record contained no orders, assessments, documentation, or care plan interventions related to the PICC line. Instead, the care plan addressed a fistula, although the resident did not have a fistula and had a PICC line. The RN initially stated she assessed the resident’s fistula, then clarified she had confused the resident with another resident, and stated dialysis took care of the PICC line. The RN also stated she was not aware of any documentation of the PICC site condition or monitoring for infection or bleeding. The DON verified the missed post-dialysis vital signs and that the care plan did not adequately identify or address interventions for the PICC line.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility did not ensure a medication error rate of less than 5%, with a reported error rate of 11.54% for 2 of 3 residents observed. During observation, an LPN administered the wrong dose of artificial tears to one resident by giving 1 drop to both eyes instead of the ordered 2 drops in each eye, and the LPN also administered 10 mg of citalopram when the physician order was for 30 mg by mouth one time a day for depression. The same resident was observed receiving medications from the LPN without the ordered dose being followed, and the LPN disposed of the one-dose vial after administration. The LPN was not wearing gloves during the eye drop administration. A second resident received the wrong medication during the medication pass. The LPN administered Calcium with Vitamin D 500 mg, 1 tablet, while the physician order was for Calcium Carbonate 1250 mg (500 Ca) and to give 2 tablets by mouth one time a day for low calcium in the blood. Facility policy stated licensed nurses are to observe the seven rights of medication administration, including the right drug and right dose. Interviews with nursing staff and the DON reflected that nurses were expected to verify medications against the MAR and medication card, clarify unclear over-the-counter medications, and wear gloves for eye drops and other specified medication tasks.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to the development and worsening of pressure injuries. Resident R29 was admitted without skin impairments but developed a stage 3 pressure injury to the coccyx, which progressed to a stage 4 due to insufficient comprehensive assessments, delayed care plan interventions, and inadequate repositioning. The facility's documentation was inconsistent, with errors in wound staging and a lack of timely updates to care plans and treatment orders. Despite being identified as high risk for pressure injuries, R29's care plan did not include necessary interventions such as pressure-reducing devices or a repositioning program until much later. Resident R18 was admitted with multiple pressure injuries, but the facility failed to document their locations, sizes, or stages accurately. The care plan for R18 included repositioning every 1-2 hours and specific post-meal positioning, but these interventions were not consistently implemented. Observations revealed that R18 was often left in the same position for extended periods, contrary to the care plan instructions. The facility's documentation of R18's pressure injuries was unclear and contradictory, with no new interventions implemented despite the presence of multiple pressure injuries. The facility's interim Director of Nursing (DON) acknowledged the deficiencies in wound care and documentation, noting that wound assessments were not being recorded accurately and were scattered across different sections of the electronic health record. The interim DON initiated a facility-wide skin sweep and a Performance Improvement Plan (PIP) in response to the identified issues. However, the report focuses on the facility's failure to prevent the development and worsening of pressure injuries for residents R29 and R18, highlighting significant lapses in care and documentation.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification to residents or their legal representatives regarding the reasons for transfer or discharge for five out of six residents reviewed. This deficiency was identified through interviews and record reviews conducted by the surveyor. The facility's policy mandates that before a resident is transferred or discharged, the resident and their representative must be notified in writing of the reasons, proposed date, and location of the transfer. However, in the cases of residents R10, R14, R25, R8, and R15, no such written notices were provided. For instance, R10 was transferred to the emergency department for medical reasons, but no notice was given to their legal representative. Similarly, R14, who had severe cognitive impairment, was transferred multiple times without written notification to their representative. Other residents, such as R25, R8, and R15, were also transferred to hospitals due to medical conditions, yet their records lacked the required written notices. Interviews with the Interim Director of Nursing and Social Services staff revealed a lack of clarity and responsibility regarding the issuance of these notices, contributing to the deficiency.
Failure to Provide Bed Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives during facility-initiated transfers to hospitals or therapeutic leaves. This deficiency was identified for five out of six residents reviewed for hospitalization. The facility's policy requires that residents receive written information about the state's bed hold duration and payment amount before transfer, but this was not adhered to in multiple cases. For instance, one resident was transferred to the emergency department for right lower quadrant pain, and no bed hold notice was given to their legal representative. Another resident with severe cognitive impairment was transferred multiple times to the emergency room, yet no written bed hold notice was documented or provided to their legal representative. Interviews with facility staff revealed a lack of clarity and responsibility regarding the issuance of bed hold notices. The Interim Director of Nursing (DON) and Social Services (SS) staff indicated confusion over who was responsible for providing these notices. The previous DON was reportedly handling the notices, but the current staff had not continued this practice. This oversight resulted in the failure to provide necessary documentation to residents or their representatives, as evidenced by the absence of bed hold notices in the medical records of several residents who were transferred to hospitals.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity during meal assistance, as observed by surveyors. Certified Nursing Assistants (CNAs) were seen using residents' clothing protectors to wipe their mouths instead of using the provided napkins. This practice was observed with three residents, each with varying degrees of cognitive impairment and physical limitations, who required assistance with eating. Despite the availability of napkins, CNAs continued to use clothing protectors, which is not in line with the facility's policy on maintaining residents' dignity. Resident 13, who has severe cognitive impairment and is dependent on staff for meal assistance, was observed being assisted with a pureed meal by CNA I, who used the clothing protector to clean the resident's mouth. Similarly, Resident 18, with moderate cognitive impairment and total dependence for eating, was assisted by CNA E, who also used the clothing protector instead of a napkin. Resident 17, with moderate cognitive impairment and physical limitations, expressed dissatisfaction with the use of the clothing protector for wiping their face, preferring a napkin or tissue. The Interim Director of Nursing confirmed that staff should be using napkins, not clothing protectors, for this purpose.
Resident Lacks Access to Call Light
Penalty
Summary
The facility failed to ensure that a resident, identified as R18, had access to a call light, which is necessary for requesting assistance. R18, who was admitted with multiple diagnoses including vascular dementia, hemiplegia, and pressure ulcers, was observed multiple times without the call light within reach. Despite R18's moderate cognitive impairment and total dependency on staff for mobility and other activities, the call light was consistently found draped underneath the pillow or out of reach, preventing R18 from effectively communicating needs to the staff. Throughout the observations, R18 was noted to be yelling for assistance, indicating discomfort and a need for help, yet the call light remained inaccessible. Staff members, including CNAs and an LPN, were informed of R18's needs but did not ensure the call light was placed within reach. The Interim Director of Nursing acknowledged that the expectation is for all residents to have call lights within reach, but this was not adhered to in R18's case, as confirmed by a CNA who admitted to being unaware of the call light's inaccessibility due to being busy.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in maintaining their baseline Activities of Daily Living (ADLs). For one resident, who was admitted with conditions including hemiplegia and hemiparesis following a stroke, the facility did not incorporate a restorative range of motion program into the care plan, despite recommendations from physical therapy. This resident expressed concerns about not receiving appropriate services to maintain some independence, resulting in total reliance on staff for all care. The Interim Director of Nursing was unaware of the physical therapy recommendation and acknowledged the absence of a restorative care plan. Another resident, with severe cognitive impairment and multiple medical conditions, did not have a care plan addressing personal preferences and dependency on staff for assistance with ADLs such as showering, dressing, oral care, and bed mobility. The surveyor noted that the comprehensive care plans for this resident were not up to date, and the Interim Director of Nursing confirmed the understanding that the care plans were lacking necessary updates.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise comprehensive care plans for two residents, leading to deficiencies in their care. Resident 14, who has severe cognitive impairment and multiple medical conditions including repeated falls and incontinence, experienced a fall on June 13, 2024. Although a new intervention of a fidget blanket was introduced to decrease anxiety, this was not included in the resident's comprehensive care plan for falls. Additionally, after being hospitalized and returning with a non-weightbearing status, the resident's bladder incontinence care plan was not updated to reflect the new condition, as it still indicated the resident should request assistance with ambulation to the bathroom. The Interim Director of Nursing acknowledged that the care plans were not up to date. Resident 17, with moderate cognitive impairment and requiring total dependent assistance for activities of daily living (ADLs), had an outdated ADL care plan. Despite the resident's need for total assistance and use of a Hoyer lift for transfers, the care plan still stated that the resident could transfer with an EZ stand and participate in dressing tasks. This discrepancy was observed during a survey, and the Interim Director of Nursing was unaware of the outdated care plan, indicating a lack of awareness of the resident's current ADL needs.
Failure to Provide Toileting and Hygiene Care
Penalty
Summary
The facility failed to provide necessary services for toileting and personal hygiene to a resident, identified as R14, who was unable to carry out activities of daily living independently. R14 had a range of medical conditions, including severe cognitive impairment, muscle weakness, and incontinence, which required staff assistance for transfers, toileting hygiene, and other personal care activities. Despite these needs, observations revealed that R14 was left sitting in a Broda chair by the nurse's station for extended periods without being taken for incontinence care or being asked if they needed to use the bathroom. On the day of observation, R14 was seen being moved to the dining room for meals but was not provided with toileting care before or after meals, as confirmed by interviews with staff. A Certified Nursing Assistant (CNA) indicated that R14 was last toileted in the morning and would only be taken to the bathroom upon request, despite R14's severe cognitive impairment. The Interim Director of Nursing acknowledged that residents should be toileted before and after meals, indicating a lapse in the facility's adherence to care protocols for dependent residents.
Failure to Implement Restorative Care Program for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to maintain or improve their condition. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was discharged from physical and occupational therapy with a recommendation for a restorative range of motion program. However, this program was never implemented, leading to a decline in the resident's mobility and activities of daily living (ADL) functions. The resident expressed feeling totally reliant on staff for care, indicating a lack of independence that could have been mitigated with proper restorative care. During the survey, it was observed that no restorative care was provided to the resident over a three-day period. Interviews with staff, including CNAs and the Interim Director of Nursing, revealed a lack of awareness and implementation of the recommended restorative program. The restorative program book, which should have contained the resident's program, did not include any information for the resident, and staff were not completing the necessary exercises. This oversight resulted in the resident not receiving the care needed to maintain or improve their range of motion, as recommended by therapy professionals.
Medication Labeling Deficiency for Insulin Pen
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically concerning the labeling of insulin pen medications. During a medication administration observation, a surveyor noted that an insulin pen for a resident with diabetes mellitus II was labeled incorrectly. The label on the insulin pen indicated a fixed dose of 7 units to be administered before lunch, which did not match the physician's order for a sliding scale dosage based on blood sugar levels. The discrepancy was confirmed by the RN administering the medication, who acknowledged that the pharmacy had been sending insulin pens with incorrect labels following a change in the order. The Director of Nursing (DON) confirmed that the facility's policy required verification of medication labels upon receipt from the pharmacy and during administration. The DON stated that any discrepancies should be corrected by applying a sticker to verify the order with the Medication Administration Record (MAR) before administration. However, in this case, the error was not corrected when the insulin pen was first received, and no evidence was provided that the pharmacy had been notified of the labeling error. This oversight had the potential to harm the resident involved.
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not performing proper hand hygiene during care procedures for two residents. The facility's policy on hand hygiene, dated 02/02/24, clearly states that hand hygiene must be performed before donning gloves and immediately after removing them. However, during observations, Certified Nursing Assistants (CNAs) D and E did not adhere to this policy while providing morning and catheter care for residents R2 and R29. For instance, CNA D was observed changing gloves multiple times without washing hands or using hand sanitizer while providing care to R2, who was on enhanced barrier precautions due to an indwelling Foley catheter. Similarly, during care for R29, CNA E also failed to perform hand hygiene between glove changes. Despite using hand sanitizer and donning gloves before entering the room, CNA E did not wash hands or use hand sanitizer after removing gloves during perineal care and other procedures. These actions were contrary to the facility's infection control practices and policies. The Interim Director of Nursing acknowledged the observations and confirmed that the CNAs did not follow the required infection control practices.
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 63 citations issued within 25 miles in the last 12 months — including the 1 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 Barron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dove Healthcare - Rice Lake | 8.4 mi | ★★★★★ | 15 | 0 |
| Heritage Lakeside | 9.2 mi | ★★★★★ | 15 | 1 |
| Meadowbrook At Chetek | 11.4 mi | ★★★★★ | 19 | 0 |
| Care And Rehab - Cumberland | 12.2 mi | ★★★★★ | 14 | 0 |
| Golden Age Manor | 26 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 July 2026) and official state health department websites.