Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Bayshore Nursing & Rehab during CMS and state inspections, most recent first.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
A facility was cited for systemic failures in wound care, pressure injury prevention, medical oversight, and DON coverage. Surveyors found that clinical procedural changes were made without standards-based oversight, the MD deferred wound issues and was unaware of the wound program breakdown, and QAPI did not identify the problems. Two residents experienced severe wound deterioration, infection, hospitalization, and amputations, while another developed multiple pressure injuries that progressed to necrotic ulcers and sepsis.
The Medical Director did not carry out his responsibilities for coordinating resident care, wound oversight, QAPI participation, and infection prevention oversight. He stated he deferred wound care to the wound team and a Wound MD, was unaware of serious wound issues affecting two residents, and did not know the facility had made wound care changes outside clinical standards. Surveyors also found gaps in infection surveillance, antibiotic stewardship documentation, and vaccination records for multiple residents and a staff member, with the issue cited as Immediate Jeopardy.
Failure to Assess Wounds and Monitor Falls: A resident with diabetes, lupus, and severe mobility impairment developed multiple non-pressure wounds after a fracture and surgery, but RN assessments were not completed, wound changes were not comprehensively monitored, and ordered follow-up was missed, leading to worsening infection and eventual amputations. The record also showed another resident had unwitnessed falls without neuro checks and delayed provider follow-up after hospital evaluation.
Failure to Provide Timely Pressure Injury Care and Prevention: The facility did not ensure residents with pressure injuries or at risk for skin breakdown received timely assessments, ordered treatments, and prevention measures. One resident with multiple worsening pressure injuries developed severe infected buttock wounds, sepsis, and Fournier's gangrene, while another had repeated gaps in comprehensive skin assessments and delayed wound treatment implementation. Additional residents developed facility-acquired pressure injuries or were observed without ordered heel offloading and other care plan interventions.
A resident with multiple neurologic and mobility diagnoses fell while transferring to the bathroom and later was found to have pelvic fractures; the fall review noted poor lighting, an unlocked wheelchair, and bare feet, and the resident’s wheelchair lacked the anti roll back brakes in the care plan. Another resident with stroke-related hemiplegia had repeated unwitnessed falls, but the fall reviews did not fully address all contributing factors such as an unlocked wheelchair, lack of adaptive equipment use, and oxygen not being worn as prescribed. A third resident with moderate cognitive impairment and a smoking care plan was observed smoking outdoors without staff supervision, despite incomplete smoking safety assessments and documented need for smoking safety oversight.
RN coverage and DON staffing deficiency: The facility did not have an RN in the building for at least 8 consecutive hours on one day reviewed, and it also lacked full-time DON coverage during two separate periods. Schedule review and staff interviews confirmed there was no RN present, while the NHA and DON described gaps in DON coverage related to a leave of absence, a DON walking out, and delays tied to the new DON’s transition from another job.
Food safety practices were not followed in the kitchen when a scoop was left in a flour bin instead of its holder, silverware was stored uncovered next to the serving line overnight, and dietary staff with facial hair were observed plating food without beard restraints. The DD stated the facility did not have beard restraints available and staff reported they had never been asked to wear them.
Inaccurate PBJ Staffing Submission: The facility did not accurately submit PBJ staffing data to CMS for a quarter, resulting in excessively low weekend staffing and a one-star staffing rating. Review of weekend schedules showed nurses and CNAs on each shift, including agency and call-ins, while interviews with staff and the NHA indicated staffing was generally covered; however, the NHA stated weekend manager bonus coverage was not coded correctly in payroll for the quarter.
QAPI Committee Failed to Identify and Correct Systemic Deficiencies: Surveyors found that the facility did not have an effective QAPI process to identify and correct systemic problems before multiple deficiencies were cited. The NHA and DON stated that QAPI meetings were inconsistent, PIPs for wounds, falls, admissions, and infections were only being developed, and there were gaps in DON coverage and clinical oversight. Meeting minutes did not address major changes to wound care or the discontinuation of the falls investigation process, and the facility could not confirm required QAPI attendees participated.
The facility did not maintain an effective IPCP. The WMP team was outdated and did not include the IP, there was no committee or documented testing for control measures such as disinfectant levels or Legionella, and the Facility Assessment omitted infection prevention and water management details. The 2025 surveillance logs were incomplete, missing January documentation, infection rates, McGeer review, and several resident infections. In addition, a resident with eye drainage and treatment for a contagious eye infection was not placed on contact isolation when staff provided care, and staff entered the room without PPE or isolation signage.
Failure to Document and Monitor Antibiotic Use: The facility did not implement its antibiotic stewardship program as required. The DON reported the IPC module in the EHR was disabled, preventing access to antibiotic records and reports, and surveyors found no antibiotic use documentation or McGeer's criteria assessments in the medical record or surveillance log for the year reviewed. The IP said McGeer's criteria were used, but the related sheets were only discussed at the 24-hour meeting and were not part of the permanent record.
Missing COVID-19 Immunization Documentation for Residents and Staff: The facility failed to document COVID-19 vaccine education, offering, receipt, or refusal for multiple residents and one CNA. Surveyors reviewed records for cognitively intact residents, a resident with a HCPoA, and a resident with moderate cognitive impairment, but found no evidence the vaccine was offered or declined. The DON stated no COVID-19 vaccinations had been offered since 2023, and staff records also lacked documentation because COVID-19 vaccination was not offered to staff.
The facility did not maintain an effective pest control program, and surveyors observed repeated fly and fruit fly activity in resident rooms, hallways, and around a meal cart on multiple units. Residents and staff reported the flies and gnats had been ongoing for months, with residents using fly swatters, fly strips, fans, and closed doors to cope with the problem. The DON stated there was no pest control policy, and pest control records showed recurring concerns such as midges in light traps, fly activity in fly lights, doors left open, fruit flies around drains, food debris in rooms, and ants in resident areas.
Missing Compliance and Ethics Training Documentation: The facility did not have documentation that 7 of 8 sampled staff members, including CNAs, an SLP, and an RN, completed annual compliance and ethics training. The surveyor requested proof from the NHA and DON, reviewed the available training records, and found no evidence for those staff members. The NHA later stated that no additional information could be located.
Missing Behavioral Health Training for Multiple Staff: Record review and interview showed that 7 of 8 staff selected at random had no documentation of behavioral health training, including CNAs, an RN, an SLP, and housekeeping staff. The NHA stated the facility did not have a policy on required annual in-service training, and Relias records also lacked evidence of annual compliance and ethics training for the same staff. The NHA and DON acknowledged the missing training.
The facility did not ensure that residents whose Medicare Part A benefits ended received required written beneficiary protection notices. Four of 5 sampled residents did not receive an ABN with financial liability information and appeal rights when coverage ended, and only one NOMNC could be located during survey review. The NHA stated the staff member who had handled the notices had died and the work was still being redistributed.
Failure to address a Resident Council grievance about staff name tags. Residents raised concern that staff were not wearing name tags, but the issue was not documented as a grievance or shown to be thoroughly investigated or resolved. During survey observations, multiple staff members, including LPNs, CNAs, the DOR, and housekeeping staff, were still not wearing name tags, and the DOSS acknowledged awareness of the concern without having addressed it as a grievance.
A facility failed to ensure MDS assessments accurately reflected resident status. Multiple residents were coded as not requiring PASARR level 2 even though PASARR records showed serious mental illness or related conditions, and other MDSs were inaccurate for Foley catheter use, dental status, and anticoagulant use. Interviews with the MDS Coordinator, DON, and NHA confirmed the inaccurate coding and that the MDS Coordinator was responsible for completing the assessments.
Lack of Meaningful Activity Programming on C Wing: The facility did not provide an ongoing activity program to support residents’ interests and well-being on the C wing. Surveyors observed residents sitting without activity engagement, with a muted TV in the dining area and age-inappropriate items such as desktop bells and play food placed on the table. A CNA said no current activity calendar was available and nothing was scheduled that staff were aware of, and the Activity Director could not provide prior activity calendars. Review of the September activity calendar showed limited programming on Sundays besides televised football games.
Missing Annual CNA Performance Reviews: The facility did not complete annual performance reviews for 3 of 4 CNAs reviewed, including CNA-JJ, CNA-OO, and CNA-PP. Staff said CNA evaluations are due on each employee's anniversary date, monthly emails identify staff due for review, and the review form is kept on the shared drive for supervisors, but only one of four requested CNA performance reviews was available and no reason was provided for the missing evaluations.
Pharmacy recommendations were not consistently acted upon or documented for multiple residents. Surveyors found missing physician responses, undated MRRs, and no evidence that recommendations for psychotropic meds, GDRs, lab monitoring, or medication changes were followed up on for residents with diagnoses including dementia, psychosis, depression, schizophrenia, bipolar disorder, COPD, and other chronic conditions. The DON acknowledged the facility lacked documentation showing the recommendations were addressed.
An LPN's medication cart contained multiple insulin pens and open stock medications that were not dated when opened. Surveyors observed undated Lispro and several resident insulin pens in a drawer on the B hallway cart, and the facility's policies required opened multidose vials and certain opened medications to be dated. When questioned, the LPN said the medications would be discarded and replaced, and the DON later said the issue had been taken care of.
Failure to Document Offering Pneumococcal Vaccines: The facility did not document that pneumococcal immunizations were offered, or refused, for 4 of 5 reviewed residents. The affected residents included cognitively intact residents and one resident with an activated HCPOA; none had record evidence of vaccine offer, refusal, or required education/VIS documentation, despite facility policy requiring admission assessment, education, and documentation for pneumococcal vaccination.
A facility failed to develop and implement individualized care plans for four residents with psychiatric, mood, or behavior-related diagnoses. Records and staff interviews showed missing or incomplete care plan interventions for a resident with dementia and agitation, a resident with schizoaffective disorder and anxiety, a resident with depression, and a resident with depression, bipolar disorder, and hoarding disorder; staff confirmed that behavior interventions should have been care planned, but the records did not contain them.
The facility did not ensure that two residents and/or their representatives were informed of the risks and benefits of prescribed psychotropic medications. One resident with dementia, schizophrenia, pica, and behavioral disturbance received antipsychotic and anti-anxiety medications, and another resident with major depressive disorder, psychosis, and dementia received antipsychotic, antidepressant, and anticonvulsant medications. Surveyors found no documentation that consent, risks, benefits, or alternatives were reviewed or provided, and the DON stated no medication consents could be located.
Resident phone access lacked privacy. A resident reported that residents without cell phones had no in-room phones and had to use the nurse's station, where there was no privacy. Staff directed residents to phones at the nurse's station, receptionist desk, Social Services office, or a high-traffic area by the vending and ice machines, and the surveyor observed that these locations were not private.
A resident’s room floor was observed to be very sticky over multiple days, and the resident was unsure whether the floor had been mopped recently. The resident had intact cognition, used a walker, and required assistance with mobility. Housekeeping stated resident floors are supposed to be swept and mopped daily, but had not been made aware of the sticky floor when the surveyor raised the concern.
A resident with schizophrenia, dementia, epilepsy, and movement disorder received Haldol Decanoate and Olanzapine, but the facility did not complete required AIMS monitoring for an extended period. The record showed a gap in AIMS documentation despite the facility policy requiring testing on admission, quarterly, with significant change, and with antipsychotic changes. The DON stated the missed AIMS assessments were discovered during an internal audit.
A facility failed to provide proper written transfer and bed-hold notices to two residents who were sent to the hospital. One resident’s notice lacked the reserve bed payment rate/policy detail, and another hospital transfer had no notice in the chart; staff also stated copies of the forms were scanned into the record and not given to the resident or representative. The residents had multiple medical conditions, including stroke-related weakness, diabetes, amputation, opioid dependence, and depression, and one resident had intact cognition with a BIMS score of 15.
A resident with PTSD and depression had a PASARR level 1 indicating suspected serious mental illness and need for a level 2, but the facility did not complete the level 2 within the required timeframe. The resident also had orders for anxiety/depression meds and behavior monitoring, while the DON and DSS gave differing explanations for the delay before acknowledging the error.
Failure to provide needed nail care and urinal assistance. A resident with stroke-related hemiplegia, impaired ROM, and diabetes was dependent for multiple ADLs and had care plans for nail care and toileting assistance, but surveyors repeatedly observed extremely long fingernails and a urinal left half-full hanging at the bedside. The resident stated the nails had not been cut in a long time, and an LPN described routine urinal emptying and nail-cutting practices that were not reflected in the resident’s observed care.
A resident with PTSD, depression, anxiety, bipolar disorder, and a history of abuse did not have a person-centered care plan for PTSD triggers or interventions, and the CNA Kardex also lacked this information. Nursing documented the resident had no trauma history, even though psych notes later identified childhood mental, verbal, physical, and sexual abuse. Staff, including the CNA, LPN, DON, and DSS, were unaware of the resident’s PTSD triggers, and quarterly trauma assessments were not completed after the initial assessment.
Incomplete bed rail assessment and missing orders, consent, and monitoring. A resident with hemiplegia, CHF, vascular disease, depression, and anxiety was observed in bed with partial bilateral bed rails, but the record lacked evidence of attempted alternatives, a complete rail assessment, signed consent, a device evaluation, physician orders, and monitoring for side effects. The assessment documented only the right rail, while bilateral rails were present, and the DON confirmed no order, consent, evaluation, or monitoring was in place.
The facility did not ensure a resident with broken and missing teeth received needed dental services. The resident, who had dysphagia, chronic respiratory failure, and COPD, reported that no one had helped him see the dentist, and the surveyor observed broken and missing teeth. The record showed a dental exam documenting the need for additional oral surgery for extractions, but no oral surgery appointment had been made, and the DON confirmed the resident had not yet been seen by an oral surgeon.
A resident with morbid obesity, COPD, and type 2 DM was transferred to the hospital, but the medical record did not document the reason for the transfer, the receiving hospital, or any nursing assessment supporting the decision. The DON stated she had no information and expected nurses to document an SBAR when a resident is discharged to the hospital.
The facility did not ensure that 1 of 4 sampled CNAs completed the required annual 12 hours of in-service training. The business office reported that CNA-JJ had only 2.1 hours, then 5.6 hours, of training in the last year, which remained below the required amount. The facility said it performs monthly audits and that the CNA must have been overlooked.
Failure to Timely Report Abuse Allegations and a Fall With Fracture: A resident with major depressive disorder and alcoholic cirrhosis alleged verbal abuse by staff, but the report was not sent to the state within the required 2-hour timeframe. Another resident with multiple neuropsychiatric diagnoses and a legal guardian fell and sustained pelvic/sacral fractures, yet the incident was not reported to proper authorities. A third resident with depression and prior TIA/cerebral infarction alleged a CNA pushed her in the chest, and the facility did not timely report the abuse allegations to state or local agencies.
A facility did not thoroughly investigate multiple abuse allegations and a fall with fracture. One resident’s verbal abuse allegation lacked interviews with other residents, another resident’s fall investigation lacked staff statements and details about last checks or toileting, and a third resident’s grievance and abuse allegations contained conflicting statements and missing documentation. The DON and NHA acknowledged the investigations were incomplete.
State Survey Binder Not Readily Accessible: The facility did not ensure the most recent State Survey results were readily accessible to residents, family members, and legal representatives. During a Resident Council meeting, residents said they did not know where to view the survey binder, and the surveyor observed that the binder was not posted where it was supposed to be in the lobby. The NHA stated the binder had been placed there but kept disappearing and had been taken out of the building more than once.
A resident with multiple medical conditions who did not eat facility food relied on family-delivered meals and requested staff assistance to heat them. After the unit microwave broke, staff were instructed to use the kitchen, but a dietary aide refused to heat the resident's meal during kitchen clean-up, despite prior approval from the dietary manager. The resident's requests were not consistently accommodated, and limitations were placed on when food could be heated, contrary to facility policy on resident rights and self-determination.
Two residents did not receive adequate supervision or assistance devices to prevent elopement and falls. One resident with cognitive impairment and a history of wandering was found outside after a fall and later went missing overnight, eventually being located by police over a mile away. Both incidents lacked thorough investigation, timely care plan updates, and proper assessment upon return. Another resident fell from bed due to unlocked bed wheels, despite care plan instructions. The facility failed to ensure door alarms were functional and did not consistently monitor or document at-risk residents, resulting in immediate jeopardy.
A CNA verbally abused a resident with moderate cognitive impairment, and the incident was witnessed by a receptionist who failed to immediately report it as required by policy. The CNA continued working the rest of the shift, and the abuse was not reported or investigated until the following day, delaying protective actions for the resident and others.
Two residents' allegations of verbal abuse and misappropriation were not immediately reported to the NHA or Social Worker as required by facility policy. In one case, a resident with moderate cognitive impairment was verbally abused by a CNA, but the incident was only reported the next day after a note was found by the Social Worker. The CNA continued working on the unit until suspension the following day. Another resident's allegation of misappropriation was also not promptly reported, resulting in delayed notification to the State Agency.
A deficiency was cited when a resident did not receive sufficient food and fluids to maintain their health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
The facility did not employ a certified dietary manager or food service manager, and the current Dietary Director lacked required qualifications and was not enrolled in a certification program. The contracted Registered Dietitian provided only part-time on-site supervision, with the remainder of duties performed remotely. This deficiency affected all residents, as the facility failed to meet regulatory requirements for qualified food and nutrition service leadership.
The facility did not provide evidence that five CNAs completed annual competency reviews or the required 12 hours of in-service training, as outlined in the facility's assessment and federal regulations. Both the DON and NHA confirmed the lack of documentation for these training and competency requirements.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Systemic failures in wound care oversight and administration
Penalty
Summary
The facility was cited for failing to administer the building in a manner that enabled effective and efficient use of resources to support residents’ highest practicable well-being. Survey findings described systemic breakdowns in wound care, pressure injury prevention, medical oversight, nursing leadership, and QAPI. The report states that procedural changes were implemented by Operator-FFF that were not based on clinical standards of practice, and that the facility did not maintain a full-time DON during key periods. The medical director deferred wound concerns to the wound physician, did not know who the wound physician was, and was unaware that the facility lacked systems for ongoing assessment, treatment, and monitoring of residents with wounds or at risk for wounds. Two residents were described in detail as having serious wound-related deterioration. One resident with a surgical left leg wound and multiple other wounds had not been comprehensively assessed or treated according to orders, and the wound worsened to the point of infection, necrosis, hospitalization, hardware and bone involvement, and eventual left above-knee amputation. Another resident with excoriation, a diabetic toe ulcer, and a scrotal abscess had wound care and monitoring concerns documented, later developed severe infection including Fournier’s gangrene and sepsis, and required hospitalization and surgical intervention. The report also states that another resident developed multiple pressure injuries, including deep tissue injury and unstageable wounds, with delayed or absent assessments and treatments, later progressing to necrotic ulcers, sepsis, and amputations. Surveyors found that the facility’s leadership did not identify or address these systemic failures through its QAPI process. The report states that QAPI meetings did not address the dismantling of wound care practices, the lack of clinical oversight during periods without a full-time DON, or the medical director’s lack of coordination of care. The facility was cited for 39 deficiencies in total, including immediate jeopardy findings for administration, quality of care, treatment/services to prevent or heal pressure ulcers, medical director responsibilities, and the absence of a full-time DON.
Medical Director Failed to Coordinate Resident Care and Oversight
Penalty
Summary
The facility did not ensure the Medical Director followed through on responsibilities for implementing resident care policies and coordinating medical care. The Medical Director agreement stated he was to supervise and coordinate resident care, assist with emergency coverage and treatment procedures, review incident reports, participate in surveys and complaints, help develop and monitor written policies governing resident care, advise the Administrator on adequacy of resident care services and equipment, serve on the QAPI committee, and make routine visits to discuss resident care problems and staff needs. During interview, the Medical Director stated he visited the facility every other week, that his NP visited two to three times a week, and that he participated in QAPI meetings, but he also stated he let the NHA deal with recent ownership transitions and typically was not involved with wounds, especially complex wounds. The Medical Director stated he deferred all wound care to the facility wound team and the Wound MD, and said he was only involved if there was an emergency and the Wound MD could not be reached. He was not sure who the facility Wound MD was and named a physician the surveyor noted the facility no longer worked with. When surveyors explained that two residents had developed pressure and non-pressure wounds that progressed to serious concerns requiring hospitalization and affecting quality of life, including systemic infections and/or amputation, the Medical Director stated he was not aware of any wound management issues and reiterated that he deferred to the wound team. He also stated wound concerns were not discussed with him or in QAPI meetings. The Medical Director was also not aware that the facility had implemented wound care procedural changes that were not based on clinical standards of practice, and he was not aware the facility did not maintain a full-time DON during the period those changes were implemented. The report states he did not fulfill his role on the QAA committee by failing to assist with administrative decisions, including recommending, developing, and approving policies and procedures related to resident care, coordination of medical care, and implementation of policies and procedures. He also did not work with the clinical team to provide surveillance and develop policies and procedures related to infection prevention, antibiotic stewardship, and vaccinations. Surveyors found no documentation of antibiotic use assessments or McGeer criteria in the surveillance logs or medical records reviewed, and several sampled residents and one staff member had no documentation showing they were offered, received, or declined pneumococcal or COVID-19 vaccination. The facility identified this as Immediate Jeopardy beginning 9/9/2025, and the report states the immediate jeopardy was not removed prior to survey exit.
Failure to Assess and Treat Wounds and Monitor Falls
Penalty
Summary
The facility did not ensure residents received treatment and care according to orders, resident preferences and goals, and professional standards of practice for non-pressure wounds, changes of condition, neurological checks after unwitnessed falls, and physician follow-up. The report identified immediate jeopardy related to the facility’s failure to comprehensively assess non-pressure wounds, implement interventions based on clinical condition and risk factors, and provide care consistent with professional standards of practice for R97 and R98. The immediate jeopardy began on 1/09/2025 and was not removed at the time of survey exit. R97 was admitted with multiple chronic conditions including diabetes, lupus, agranulocytosis, heart failure, acute kidney failure, anxiety, and depression, and had impaired mobility. After a fall with a left tibia/fibula fracture and surgical repair, the hospital discharge instructions included keeping the dressing in place until an orthopedic follow-up visit. On readmission, an RN did not assess R97’s skin, and multiple wounds were documented by LPNs without RN assessment or verification. The record showed wounds to the left heel, left lateral foot, left medial ankle, left dorsal foot, and a surgical wound to the left lateral knee, but these were not comprehensively assessed by an RN or the wound physician. The orthopedic follow-up was missed, and later the orthopedic clinic documented significant wound breakdown because the resident had not been seen at the scheduled follow-up. The wound required debridement, packing, and antibiotics. Throughout the record, wound logs were maintained by an LPN but were not part of the medical record and were not signed or verified by an RN. R97’s wound care continued to deteriorate with repeated documentation of additional wounds, pain, drainage, necrosis, exposed bone, and infections, while assessments remained incomplete or absent. The resident was hospitalized multiple times for worsening wounds, including concern for osteomyelitis, surgical removal of hardware, and later above-the-knee amputations. The record also showed new wounds on the right thigh, right foot, right ankle, and other areas after subsequent hospitalizations, with delayed initiation of ordered treatments and no RN skin assessments on readmission. For R73, the report states the resident had unwitnessed falls on 6/25/2025, 7/1/2025, and 7/3/2025, but neurological checks were not completed. After the 7/1/2025 fall and hospital evaluation, there was an order for primary care follow-up in one week, but the resident did not see the NP until 7/30/2025, and that documentation did not address follow-up or evaluation of the falls.
Failure to Provide Timely Pressure Injury Care and Prevention
Penalty
Summary
The facility did not ensure residents with pressure injuries or at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent new pressure injuries and promote healing. Surveyors identified systemic failures in wound care and prevention, including the absence of established wound care policies reviewed and approved by the medical director, no system to ensure risk factors were appropriately assessed and addressed, and no established system to monitor and assess wounds based on standards of practice. The immediate jeopardy was not removed prior to survey exit. One resident was admitted with a history of a stage 2 pressure injury to the right buttock and had multiple skin and wound concerns documented during the stay, including a right coccyx pressure injury, unstageable pressure injuries to the right ischium and sacrum/right buttock, and later injuries to both heels. Documentation showed missed or incomplete wound assessments, no clear documentation of what wounds required treatment or measurement on some dates, delayed initiation of ordered treatments, and no comprehensive skin assessment on admission. The resident was later sent to the emergency room with severe infection, and hospital records documented necrotic ulcers on both buttocks with foul odor and drainage, severe sepsis, Fournier's gangrene, stage 4 pressure injuries to both buttocks, a deep tissue injury to the right heel, and an unstageable pressure injury to the left heel. Surgical debridement found necrotic tissue with significant fat and muscle necrosis, and one wound tracked to bone. Another resident did not have comprehensive skin assessments on multiple readmissions, developed worsening heel and foot wounds, and had wound treatments that were not implemented timely or were ordered for wounds that were not assessed or documented. Wounds were not comprehensively assessed weekly by an RN after the resident stopped being seen by the wound physician. Additional residents were also affected: one developed a facility-acquired stage 3 sacral pressure injury, another developed a facility-acquired stage 3 sacral pressure injury and was observed not wearing heel boots per the care plan, and another resident with a history of a heel DTI was observed with the heel directly on the bed and not offloaded, with the care plan not revised to reflect patient-specific interventions.
Inadequate supervision during falls and smoking
Penalty
Summary
The facility did not ensure adequate supervision and assistance devices were in place to prevent accidents for three residents. One resident with diagnoses including epilepsy, schizophrenia, dementia, and impaired mobility had a high fall risk and a care plan requiring supervision for transfers, use of gripper socks, and a wheelchair with anti roll back brakes. After being found on the floor with the wheelchair overturned, the resident was sent to the hospital and diagnosed with a nondisplaced left sacral ala fracture and a nondisplaced fracture of the right inferior pubic ramus. The fall investigation documented poor lighting, an unlocked wheelchair, and bare feet, and survey observations later showed the resident’s wheelchair did not have the anti roll back brakes called for in the care plan. A second resident with hemiplegia and hemiparesis following a cerebral infarction, depression, anxiety, chronic pain syndrome, and alcohol abuse had repeated unwitnessed falls. The resident’s care plan included multiple fall-prevention interventions, including offering toileting, visual checks, and use of a wheelchair with a dump seat. After a fall in which the resident slid from the wheelchair, staff documented the wheelchair was not locked and the resident was not using prescribed adaptive equipment or oxygen. Another unwitnessed fall occurred when the resident tried to walk to the bed, and a third fall occurred when the resident was found on the floor after trying to walk. The fall reviews did not include all identified contributing factors, such as the unlocked wheelchair, lack of adaptive equipment use, and oxygen not being worn as prescribed, and no thorough root cause analysis was documented for each event. A third resident with stroke-related hemiplegia and moderate cognitive impairment was a current smoker with a smoking care plan that required smoking safety assessment and supervision as indicated. The resident’s smoking assessments were incomplete and did not address limited range of motion or inability to extinguish tobacco safely. Survey observation showed the resident smoking outside in the designated area without staff supervision, while seated in a wheelchair, wearing regular socks and no shoes, with one arm in a sling. The resident stated there was no staff present while smoking, that the resident lit the cigarette independently, and that the cigarette was tossed on the ground without staff present to extinguish it.
RN Coverage and DON Staffing Deficiency
Penalty
Summary
The facility did not use the services of an RN for at least 8 consecutive hours a day, 7 days a week, and it did not ensure full-time DON coverage. Survey review of nursing schedules and nurse staff postings for the 30 days before the survey showed no RN scheduled or present in the building on 8/30/25. The facility assessment documented RN coverage 24 hours per day, but the surveyor found that the schedule did not reflect any RN coverage on that date. During interviews, the Scheduler confirmed that 8/30/25 was a Saturday and there was no RN in the building, and the Nursing Home Administrator and DON did not provide additional information explaining why RN coverage was not maintained. The facility was also without full-time DON coverage from 4/1/25 through 5/12/25 and again from 7/31/25 until at least 8/4/25. The prior DON had a leave of absence and later walked out on 7/30/25, and the NHA stated the governing body had said it would provide clinical support but did not have anyone present in the building. The new DON signed an offer letter on 8/4/25 and had to work around notice obligations at another hospital before becoming full time at the facility, leaving a period when the facility did not have full-time DON coverage.
Food Safety Deficiencies in Kitchen Storage and Staff Hair Restraints
Penalty
Summary
Food was not stored and prepared in accordance with professional standards in the main kitchen. During observation, a red scoop was found sitting down in a flour bin under the serving table instead of in the scoop holder, and the Dietary Director stated the scoop should never be left in the flour. Surveyor also observed silverware being stored next to the serving line without being covered at any point, including overnight, and staff stated it was left there so it would be ready for breakfast. A sink was located across from the area where the silverware was stored, and the silverware remained uncovered while staff prepared the breakfast line. Surveyor also observed dietary staff setting trays for lunch while employees with facial hair were not wearing beard restraints. The Dietary Director stated the facility did not currently have beard restraints and later said the facility was using head-hair restraints until the order arrived. Two dietary aides were observed at the serving station without beard nets while lunch was being plated, and one dietary aide stated he had 2 inches of facial hair and had never been asked to wear a beard restraint since working in the kitchen. Another dietary aide stated he had never seen beard restraints at the facility and had never been offered one to wear.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to CMS for Quarter 3 (April 1-June 30, 2025) of the Payroll Based Journal. The CMS Electronic Staffing Data Submission Payroll-Based Journal policy requires long-term care facilities to electronically submit complete and accurate direct care staffing information, including agency and contract staff, based on payroll and other verifiable and auditable data. Survey review of the PBJ Staffing Data Report, CASPER Report 1705D, for fiscal year 2025 showed excessively low weekend staffing and a one-star staffing rating for the quarter. Survey review of weekend schedules from April through June 2025 showed licensed nurses and CNAs present on each shift for each unit, including call-ins, agency staff, and staff who picked up shifts, and the schedules did not appear to show excessive call-ins. During interviews, staff described staffing as generally adequate, with some comments about busy times, call lights, and occasional help between units. The NHA stated the facility had been running with 10 nurses because the census had not reached 100-112, and later said the low weekend and one-star PBJ result occurred because weekend manager bonus coverage was supposed to be coded as weekend work in payroll but was not coded that way in April, May, and June. No additional information was provided as to why the facility did not accurately submit the staffing information for the quarter.
QAPI Committee Failed to Identify and Correct Systemic Deficiencies
Penalty
Summary
The facility failed to maintain an effective QAPI process to identify and correct systemic deficiencies before surveyors cited multiple deficiencies across the building. During the recertification survey, surveyors found 39 deficiencies, including F865 for QAPI, with widespread concerns also cited at F727 for staffing, F812 for food storage and procurement, F851 for staffing data submission, F880 for infection control, F881 for antibiotic stewardship, F887 for COVID-19 immunizations, F925 for pest management, and F946 and F949 for clinical training. The facility was also out of compliance on revisit for F689 accidents and hazards, F684 quality of care, and F692 nutrition and hydration after those issues were not corrected on a prior revisit survey. Surveyors interviewed the NHA and DON about the QAPI program and found that the facility did not have current, implemented performance improvement plans. The NHA stated the prior DON took the QAPI plan, meeting minutes, and sign-in sheets when that DON resigned. The NHA also stated that QAPI meetings were difficult to hold because the State was in the facility frequently, and a meeting scheduled for the day of the interview was cancelled. The facility reported four PIPs related to wounds, falls, admissions, and infections, but these were only being formulated and were not yet in written form or completed. Surveyors noted no other PIPs had been identified in 2025 besides those four in development. The facility also had gaps in clinical leadership and oversight that affected the QAPI process. The NHA stated the prior DON was on leave from 4/1/25 through 5/12/25, and the facility did not have an on-site acting DON during that period. The NHA further stated there was a gap in DON coverage after the prior DON resigned on 7/31/25 until the rehired DON returned on 8/4/25. Surveyors found no QAPI meetings during the leave period and no meetings after the prior DON returned until an ad hoc meeting after an immediate jeopardy citation. The meeting minutes provided did not address the systemic changes to wound care practices or the discontinuation of the falls investigation process, and the facility could not provide sign-in sheets confirming required attendees participated in the QAPI meetings.
Infection Prevention Program, Water Management, Surveillance Logs, and Isolation Deficiencies
Penalty
Summary
The facility did not establish and maintain an Infection Prevention and Control Program based on current standards of practice. The Infection Prevention and Control Program lacked documentation of an effective water management program, the 2025 surveillance logs were missing pertinent information and documentation, and the Facility Assessment did not include infection prevention or water management information. The facility policy stated that the Infection Preventionist was responsible for oversight of surveillance, isolation precautions, and epidemiological investigations, and that a water management program was part of the overall infection prevention program, but the documentation reviewed did not reflect those elements. For the water management program, the facility’s team listed only the Administrator and Director of Maintenance, and the staff names included were no longer employed. The Infection Preventionist was not listed as part of the team. Interviews with the DON, Director of Maintenance, and Infection Preventionist showed there was no water management committee, no committee meetings, and no involvement by the Infection Preventionist. The Director of Maintenance stated they had only been on the job for three months, had received no training, and was unsure how much information they had. Survey review found no documentation of control measures being completed for items such as water heater checks, disinfectant level testing, or ice machine cleaning, and no documentation that Legionella testing had been completed. The building diagram provided was incomplete and did not identify several water system risk areas such as dead legs, vacant rooms, storage tanks, areas of stagnation, hand-held showers, aerators, no residual disinfectant areas, or sink and commode locations. The surveillance logs for 2025 were also incomplete. January surveillance documentation was missing, and the logs lacked infection rates, McGeer criteria documentation, antibiotic stewardship review, and identification of infectious organisms. Survey review found that two of four sampled residents who had diagnoses that should have been included were not documented in the surveillance logs, including one resident hospitalized with Influenza A and septic shock and another resident hospitalized with pneumonia. The facility stated it had been using antibiotic reports to create surveillance logs because the IPC module in the electronic record was disabled, but the records provided still did not contain the required surveillance information. R75 did not have contact isolation initiated when infection was discovered. R75 had diagnoses including schizoaffective disorder, bipolar type, generalized anxiety disorder, and paraneoplastic neuromyopathy and neuropathy, and had a BIMS score of 14 indicating cognition was intact. Survey observation showed no isolation sign, no isolation cart, and no PPE use by staff entering and exiting the room while R75 was receiving treatment for swollen, irritated eyes with drainage and erythromycin ointment was ordered for both eyes. CNA and LPN interviews confirmed staff were not using PPE and did not believe isolation was required at the time. The change-of-condition documentation showed the eye drainage and treatment order, and later interviews indicated isolation was only started after the surveyor raised the concern.
Failure to Document and Monitor Antibiotic Use
Penalty
Summary
The facility did not ensure its antibiotic stewardship program was implemented as part of the infection prevention and control program. The facility policy required antibiotic use protocols, monitoring of antibiotic use, review of antibiotic orders, random audits, and tracking of outcome measures, but survey review found no documentation in 2025 showing antibiotic use documentation or McGeer criteria assessments in the medical record or surveillance log. Surveyors reviewed the monthly surveillance records from January through the present and found no evidence that antibiotic use was being documented or monitored as required. During interview, the DON stated the IPC module in the electronic health record was disabled, and that without enabling it, orders or cases could not be added or updated. The DON also stated that attempts to print historical reports produced blank screens and that the previous owners disabled the IPC module on 8/7/25. The DON said documentation in binders was available only through December, and the new management company was trying to obtain access so information could be provided. Surveyors noted that without access to IPC, they were unable to locate or determine whether a resident had been assessed for appropriate antibiotic use. The IP stated the facility used McGeer's criteria to assess antibiotic use and explained that the previous DON would type information into sheets discussed during the 24-hour meeting. Surveyors observed that these sheets were not part of the resident's permanent medical record. The IP and DON confirmed that McGeer's criteria was the method used to assess whether a resident met criteria for antibiotics, but no documentation was available in 2025 to show that this assessment had been completed for residents receiving antibiotics.
Missing COVID-19 Immunization Documentation for Residents and Staff
Penalty
Summary
The facility did not ensure that COVID-19 immunization education, offering, acceptance or refusal, and vaccination status were documented in the medical records for 5 of 5 residents reviewed for immunizations and 1 of 1 staff reviewed. The facility policy stated that residents and staff would be offered the COVID-19 vaccine when supplies were available, that education about risks, benefits, and side effects would be provided before offering the vaccine, and that documentation would reflect the education provided and whether the vaccine was received or declined. For R6, R33, R40, R65, and R75, surveyors reviewed the electronic medical records and were unable to locate documentation showing whether each resident was offered, received, or declined the COVID-19 immunization. The records reviewed included residents with varying cognitive status: R6 and R65 were cognitively intact and responsible for self, R33 had an activated health care power of attorney and was unable to complete the BIMS, R40 had moderate cognitive impairment, and R75 was cognitively intact and responsible for self. The surveyor also noted that no documentation was found showing these residents were offered or refused the vaccine. The DON stated there had been no COVID-19 vaccinations offered since 2023 and no declinations had been found. For staff, the facility was unable to provide documentation that CNA-JJ had been offered, received, or declined the COVID-19 vaccine. Business office staff stated that COVID-19 vaccination was not offered to staff, only the Hepatitis B vaccination was offered. The facility’s records therefore did not contain the required documentation related to COVID-19 immunization status for the residents and staff reviewed.
Pest Control Program Not Effective
Penalty
Summary
The facility did not maintain an effective pest control program to address active flying pest activity in multiple areas of the building. Surveyors observed swarms of fruit flies hovering by resident room doors and throughout resident rooms on the C Unit during wound treatments, and multiple flies and fruit flies were also observed in hallways and resident rooms on the B Unit. Surveyors additionally observed flies around a meal cart, around surveyor equipment in the hallway, and a sticky fly strip hanging in a resident room on B Unit. Residents and staff reported ongoing problems with flies and gnats throughout the facility. One resident stated there were always flies flying around the bedroom and the facility, another resident said there were a lot of flies around and kept the door closed with a fan on to try to keep them away, and another resident reported gnats had been going on for at least a few months and had placed a fly strip in the room to help. A CNA stated the flies were very bad, that residents had fly swatters in their rooms, and that staff and residents had grown accustomed to having flies around because they were always there. The Maintenance Director stated the facility used a pest control company for monthly service, bait stations outside, and occasional gel treatment for ants, and that if residents complained of gnats he would check for old food and clean drains. The DON stated there was no facility pest control policy and that the facility would call the pest control company if a problem was identified. Surveyors reviewed pest control service records from several months and found repeated documented concerns, including midges in interior light traps, moderate fly activity in fly lights, doors left open allowing flying pests into the facility, fruit flies around drains, straws wedged in a drain, resident rooms with ants due to food debris, and a break in a wall allowing moisture to build up and fruit flies to flourish. Surveyors also observed a large number of ants under a desk in the upstairs conference room.
Missing Compliance and Ethics Training Documentation
Penalty
Summary
The facility did not ensure that 7 of 8 sampled staff members received training on the facility's compliance and ethics program. On 9/30/25, the surveyor requested evidence from the NHA and DON that CNA-WW, CNA-TT, CNA-XX, CNA-YY, CNA-ZZ, Housekeeping-AAA, SLP-BBB, and RN-CCC had completed compliance and ethics training. Review of the completed trainings showed there was no documentation that CNA-WW, CNA-TT, CNA-XX, CNA-YY, CNA-ZZ, SLP-BBB, or RN-CCC received annual training on the facility's compliance and ethics program. The NHA stated additional information would be sought, and later stated that no additional information was located for those staff members.
Missing Behavioral Health Training for Multiple Staff
Penalty
Summary
Behavioral health training was not provided for 7 of 8 staff selected at random, despite the facility being responsible for ensuring staff received training consistent with the requirements and the facility assessment. The staff identified as lacking evidence of behavioral health training were CNA-WW, CNA-TT, CNA-XX, CNA-ZZ, Housekeeping-AAA, SLP-BBB, and RN-CCC. The surveyor also noted that the Nursing Home Administrator stated the facility did not have a policy on required annual in-service training. During record review and interview, the surveyor requested documentation showing that the identified staff had received behavioral health training. Training records in Relias were reviewed, and there was no documentation that these staff members received training related to behavioral health. The surveyor also found no documentation that CNA-WW, CNA-TT, CNA-XX, CNA-ZZ, Housekeeping-AAA, SLP-BBB, and RN-CCC received annual training on the facility's compliance and ethics program. The NHA and DON acknowledged that no additional information could be located regarding behavioral health training for the identified staff.
Failure to Provide Medicare Coverage End Notices
Penalty
Summary
The facility did not ensure that residents whose Medicare Part A benefits had ended were given written beneficiary protection notifications. Based on interview and record review, 4 of 5 sampled residents (R15, R100, R101, and R102) did not receive a written Advanced Beneficiary Notice (ABN) at the time Medicare Part A coverage ended, even though the facility policy stated that residents or representatives should receive timely notices regarding Medicare eligibility and coverage, including a Notice of Medicare Non-Coverage (NOMNC) and ABN information with appeal rights and financial liability details. During the survey, the facility provided a list of 5 residents whose Medicare A benefits had expired, and the surveyor requested the notices that should have been given before coverage ended. The Nursing Home Administrator stated that only one NOMNC could be found and explained that the staff member who had previously completed them had worked at the facility for 30 years and had passed away, and the facility was still redistributing her work. At the end-of-day meeting, the facility was told that only one of the 5 residents appeared to have received proper notices, and no additional information was provided about why ABN information was not given to the residents or their representatives.
Failure to Address Resident Council Grievance About Staff Name Tags
Penalty
Summary
The facility did not address and resolve grievances raised during Resident Council meetings on behalf of 12 of 12 residents who attended the meeting. In the July Resident Council meeting minutes, residents expressed concern that staff were not wearing name tags, but there was no documentation that the concern was thoroughly investigated or that an appropriate resolution was reached. The facility policies for Resident Council and Grievances/Complaints both state that resident group concerns are to be considered, tracked, and responded to in writing with a rationale for the response. During the survey, the concern remained unresolved and was again raised by Resident Council members when asked whether the facility considered resident and family group views and acted promptly on grievances and recommendations. Surveyor observations on 9/15/2025 found multiple staff members without name tags, including an LPN, another LPN, the Director of Activities, two CNAs, housekeeping staff, and another LPN. The Director of Social Services stated she was aware of the concern but had not written it up or addressed it as a grievance, and the Nursing Home Administrator stated activity staff were supposed to write a grievance for every issue brought up and send it to Social Services, with grievances discussed quarterly at QAPI. No additional information was provided showing the July Resident Council concern was written as a grievance or resolved.
Inaccurate MDS Coding for PASARR, Medications, and Resident Status
Penalty
Summary
The facility did not ensure that MDS assessments accurately reflected residents’ status at the time of assessment. Record review and interviews showed multiple residents had MDS entries coded as “No” for PASARR level 2 even though their records contained PASARR documentation indicating a serious mental illness or related condition and, in several cases, a level 2 review had already been completed. Residents affected included those with diagnoses such as bipolar disorder, schizophrenia, anxiety disorder, depression, PTSD, and other mental health conditions. For one resident admitted with bipolar disorder, major depressive disorder, anxiety disorder, mild cognitive impairment, and PTSD, the quarterly MDS documented that PASARR level 2 was not required even though the resident’s PASARR indicated a major mental disorder. The MDS Coordinator stated the PASARR had not been scanned into the electronic record and said the assessment would have been coded accurately if it had been available. Similar discrepancies were identified for other residents whose MDS assessments stated PASARR level 2 was not required despite PASARR level 1 or level 2 documentation showing serious mental illness or related conditions, including residents with schizophrenia, bipolar disorder, anxiety disorder, depression, and PTSD. The survey also identified other inaccurate MDS coding unrelated to PASARR. One resident’s MDS indicated an indwelling Foley catheter even though the resident did not have one. Another resident’s MDS did not reflect dental issues despite the resident reporting missing and broken teeth and requesting dental care. A third resident’s MDS documented anticoagulant use even though the resident’s heparin had been discontinued months earlier and no anticoagulation medication was given during the lookback period. Interviews with the MDS Coordinator, DON, and NHA confirmed the MDS Coordinator was responsible for accurate completion of the assessments and that the facility was aware of the discrepancies.
Lack of Meaningful Activity Programming on C Wing
Penalty
Summary
The facility did not provide an ongoing program to support residents in their choice of activities that were designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident on the C wing. During survey observations, residents on the C wing were seen sitting in the dining area without activity engagement, including R4, R11, R48, R49, and R83 around a table with a muted television showing a morning talk show and no observed activity participation. Surveyors also observed a table with four multi-colored desktop bells and several pieces of plastic play kitchen food, including a play corn cob, carrot, and tomato, with no activity engagement observed. A CNA stated that there had previously been an activity staff member with a calendar for staff and residents to follow, but that no calendar had been seen lately and nothing was scheduled that staff were aware of. The CNA also stated that staff had placed the bells and play food out because they had nothing else to provide that morning. The Activity Director was unable to provide July or August 2025 activity calendars, and review of the September 2025 calendar showed limited to no activity programming on Sundays besides televised football games.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility did not complete a performance review at least once every 12 months for 3 of 4 Certified Nursing Assistants reviewed. The missing performance reviews were for CNA-JJ, CNA-OO, and CNA-PP, and the report stated this had the potential to affect all 85 residents who reside in the facility. The facility's Employee Handbook states that employees are subject to periodic job performance evaluations by their supervisor, usually at least annually, and that the evaluation is reviewed with the employee at the time of presentation. During the survey, Business Office staff-KK stated that CNA performance reviews are done annually on the employee's anniversary date. The surveyor requested the last completed performance review for four CNA staff and was provided only one of the four requested reviews. Staff later explained that a monthly email is sent from the Regional Human Resources Director with staff due for review, that each department with staff due is included in the email, and that the performance review document is on the shared drive for supervisors to use. Staff also stated that completing the performance reviews is the responsibility of the department head. At the end of day meeting, the surveyor informed the Nursing Home Administrator-A and Director of Nursing-B that 3 of 4 requested CNA performance evaluations were not available. No additional information was provided as to why the CNA performance evaluations were not done on at least a yearly basis.
Pharmacy Recommendations Not Addressed or Documented
Penalty
Summary
The facility did not ensure that a licensed pharmacist’s monthly drug regimen review recommendations were acted upon and documented by the physician for residents reviewed with pharmacy recommendations. Surveyors found no documented physician response and no indication that pharmacist recommendations were followed up on for 5 of 5 residents reviewed: R3, R6, R33, R58, and R66. For R58, who had diagnoses including major depressive disorder, epilepsy, extrapyramidal and movement disorder, schizophrenia, pica, and unspecified dementia with behavioral disturbance, the record showed psychotropic medication use and a BIMS score of 12. Pharmacy reviews documented recommendations related to lorazepam and gradual dose reduction for haloperidol, olanzapine, and trazodone, but the reviews in the chart were not dated and there was no documented physician response or evidence the recommendations were acted upon. The DON stated the facility had obtained copies from the pharmacist and that no other copies were available at the facility. For R33, who had diagnoses including major depressive disorder, psychosis, and dementia, the MDS documented use of antipsychotic, antidepressant, and anticonvulsant medications. Pharmacy recommendations in June, August, and September 2025 were not addressed by the facility, and the DON had no additional information about why they were not addressed. For R6, with diagnoses including dysphagia, chronic respiratory failure, COPD, dementia, and major depressive disorder, pharmacy recommendations from July and August 2025 advised discontinuing or changing several medications, including cetirizine, guaifenesin ER, lidocaine ointment, Mylanta, and simethicone, but there was no evidence of physician follow-up. For R3, with diagnoses including bipolar disorder and anxiety disorder, pharmacy recommendations from June, July, and August 2025 included discontinuing or changing artificial tears, ibuprofen, ondansetron, and oxycodone, and obtaining TSH monitoring due to levothyroxine use; there was no evidence these recommendations were followed up on, and the DON stated the previous DON had been responsible for bringing pharmacy recommendations to the provider’s attention. For R66, who had diagnoses including depression, transient ischemic attack, and cerebral infarction, the admission MDS showed a BIMS score of 15 and intact cognition. The EMR did not contain monthly medication reviews from admission through September 2025, and the only pharmacy recommendation provided was incomplete, with no response, signature, or date. The DON stated there was no documentation showing the recommendation was addressed or how it was addressed, and the NHA was informed that there was no evidence the pharmacy recommendation had been addressed by the health provider.
Undated insulin pens and open stock medications
Penalty
Summary
Drugs used in the facility were not labeled in accordance with currently accepted professional principles, including required dating when opened, for 1 of 2 medication carts reviewed. On 9/9/2025, surveyors observed Medication Cart B on the B hallway and found multiple insulin pens stored in a drawer without dates, including R12's bottle of Lispro, one of two pens for R25, one of two pens for R37, one of two pens for R54, two of three pens for R81, one of two pens for R85, and both pens for R99. Surveyors also observed open stock medications in the same cart drawer that were not dated when opened. The facility policy titled Vials and Ampules of Injectable Medications required the date opened and initials of the first person to use a multidose vial to be recorded, and the Storage of Medications policy required certain opened medications to be dated when the original seal was broken. When the surveyor interviewed the LPN about the undated medications, the LPN stated the medications would be thrown out and replaced with new stock in the cart. During the end-of-day meeting on 9/10/2025, the surveyor shared the concern with the NHA and DON, and the DON stated it had been taken care of. No additional information was provided as to why the facility did not ensure the opened insulin pens and stock medications were dated according to professional principles.
Failure to Document Offering Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure pneumococcal immunizations were offered, or documented as refused, for 4 of 5 residents whose immunization records were reviewed. The deficiency involved residents R6, R33, R65, and R75, all of whom were over the age of [AGE] and were identified as eligible for pneumococcal vaccination based on the information reviewed. The facility policy required residents to be assessed for pneumococcal immunization upon admission, offered the vaccine unless contraindicated or already immunized, educated about benefits and side effects, and given the opportunity to refuse, with documentation maintained in the medical record. R6’s MDS documented a BIMS score of 15, indicating cognitive intactness and self-responsibility. R33’s MDS did not document a BIMS because the resident was unable to complete it and had an activated Health Care Power of Attorney. R65’s MDS documented a BIMS score of 15, and R75’s MDS documented a BIMS score of 14; both were cognitively intact and responsible for self. For each of these residents, the record review found no documentation that pneumococcal vaccination had been offered or refused during the admission stay, and no evidence was provided showing that the residents or their representatives received the required education or VIS information. During the survey, the DON stated she was working on obtaining immunization information and would check the Wisconsin Immunization Record. Follow-up review found no pneumococcal vaccination information for the residents, and at the end-of-day meeting the surveyor informed the NHA and DON that pneumococcal immunizations were not offered to 4 of 5 eligible residents. The report states that no further evidence was provided showing that R6, R33, R65, or R75 had been offered or had refused the pneumococcal vaccine upon admission.
Failure to Develop Individualized Care Plans for Mood and Behavior Needs
Penalty
Summary
The facility did not ensure that a comprehensive care plan was developed and implemented for four residents with diagnosed mood, psychiatric, or behavior-related conditions. Review of records and interviews showed that R13, R75, R66, and R65 did not have individualized care plan interventions in place for staff to use based on their assessed needs and diagnoses. R13 was admitted with moyamoya disease, cerebrovascular disease, cerebral infarction, vascular dementia, and agitation. The resident’s MDS documented moderately impaired cognition, but the care plan did not address mood or behaviors, and there were no focus areas or interventions for dementia or agitation. Staff interviews confirmed that behaviors such as wandering and agitation were observed, that residents would be redirected, and that interventions should have been care planned, but the care plan did not contain those interventions. The resident was also observed agitated with another peer and using profanity, with staff separating the residents. R75 was admitted with schizoaffective disorder, bipolar type, generalized anxiety disorder, and paraneoplastic neuromyopathy and neuropathy. Although the MDS documented intact cognition, the care plan did not address mood or behaviors, and there were no interventions for schizoaffective disorder, bipolar disorder, or anxiety. R66 was admitted with depression, transient ischemic attack, and cerebral infarction, and the MDS documented intact cognition, but the care plan did not address depression or mood/behavior interventions. R65 had diagnoses of depression, hoarding disorder, and bipolar disorder, with MDS documentation of psychiatric/mood disorders and a PASARR indicating suspected serious mental illness, yet the record contained minimal or no evidence of a care plan for mood, behaviors, hoarding, or bipolar disorder, and there were no physician orders, TAR monitoring, or CNA instructions for psychiatric care or behavior tracking.
Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility did not ensure that residents and/or their representatives were fully informed of the risks and benefits of prescribed psychotropic medications. Survey review found that two residents, R33 and R58, had psychotropic medication use documented in their records, but there was no evidence that consent or education regarding the risks, benefits, or alternatives for those medications had been explained, reviewed, or provided to the resident representatives. R58 was admitted with diagnoses including major depressive disorder, epilepsy, extrapyramidal and movement disorder, schizophrenia, pica, and unspecified dementia with behavioral disturbance, and had a legal guardian. Records showed a CAA for psychotropic drug use, a Quarterly MDS indicating antipsychotic and antidepressant use, and psychiatric orders that included an increase in olanzapine for agitation related to dementia and pica, a decrease in lorazepam, and later discontinuation of lorazepam. Surveyors could not locate documentation that consent for the antipsychotic or anti-anxiety medications had been explained, reviewed, or provided to the resident representative. R33 was admitted with diagnoses including major depressive disorder, psychosis, and dementia. The Quarterly MDS documented use of antipsychotic, antidepressant, and anticonvulsant medications, and physician orders showed Seroquel, Depakote Sprinkles, and mirtazapine. Surveyors were unable to locate documentation that the risks and benefits of these psychotropic medications were reviewed or provided to the resident representative. The DON stated that no medication consents were located in the building and that if they were not scanned into the electronic record, the facility did not have a record of them.
Resident Phone Access Lacked Privacy
Penalty
Summary
The facility did not ensure that residents had reasonable access to a telephone in a place where calls could be made without being overheard. During the resident council meeting, one resident stated that if a person did not have a cell phone, there were no phones in resident rooms and that the resident had to go to the nurse's station, where there was no privacy. The report also identified that residents who wanted to use a facility phone were directed to the receptionist desk, the Social Services office, the nurse's station, or the area by the vending and ice machines. Surveyor interviews showed that staff consistently identified public or high-traffic locations for resident phone use. An LPN stated residents could use the phone at the nurse's station or by the vending machines on Unit B. The Director of Social Services said residents often used the phone in the Social Services office when she was there. A CNA said residents would be taken to the telephone by the vending machines, and another CNA believed residents could use a phone near the receptionist desk. An LPN stated residents could use the phone at the nurse's station or receptionist desk and believed there was one in the back area by Unit B, but the surveyor observed that area was by the vending machines, ice machine, and route to the smoking area. The surveyor informed the NHA of the concern that there was not a telephone available for residents to use privately, and the NHA responded that they cannot just build a room.
Sticky Floor in Resident Room
Penalty
Summary
The facility did not ensure a resident’s right to a clean, comfortable, and homelike environment for 1 of 85 resident rooms observed because R32’s floor was observed to be very sticky over multiple days. R32 was admitted with diagnoses including early-onset cerebellar ataxia, depression, anxiety, and hoarding disorder. The resident’s MDS documented a BIMS score of 15, use of a walker, set-up assistance for bed mobility and transfers, and supervision for walking 10 feet with partial assistance for walking 50 feet. During observation on 9/9/25 and again on 9/10/25, the surveyor noted that the floor in R32’s room was very sticky with each step throughout the room. When asked about recent cleaning, R32 stated staff take out garbage, sweep the floor, and clean the sink and toilet, but was not sure whether the floor had been mopped recently. The Supervisor of Housekeeping stated daily room cleaning includes disinfecting sinks, mirrors, toilets, doorknobs, bedside tables, and sweeping and mopping resident floors daily, and also stated that if housekeeping were made aware of a sticky floor, it would be mopped. The supervisor had not been made aware of any sticky floors in resident rooms when the surveyor raised concern about R32’s room.
Inadequate Monitoring of Antipsychotic Medication
Penalty
Summary
The facility did not ensure that R58’s drug regimen was free from unnecessary drugs because R58 did not have adequate monitoring while receiving antipsychotic medication. R58 was admitted with diagnoses including major depressive disorder, epilepsy, extrapyramidal and movement disorder, schizophrenia, pica, and unspecified dementia with behavioral disturbance, and had a legal guardian. The record showed that R58 received Haldol Decanoate 150 mg IM every 28 days and Olanzapine 10 mg nightly for schizophrenia, with Olanzapine increased from 5 mg to 7.5 mg and then to 10 mg. The facility policy for psychotropic medications required AIMS testing on admission, quarterly, with significant change in condition, and with changes in antipsychotic medication. Survey review of the EHR found AIMS assessments documented on 4/20/2023, 9/14/2023, 4/20/2025, and 8/29/2025, with no AIMS documented between 9/14/2023 and 4/20/2025. The CAA for psychotropic drug use documented that R58 received antidepressant and antipsychotic medications and was monitored for effectiveness and side effects, and the psychiatric note listed the current antipsychotic regimen. When interviewed, the DON stated the facility realized AIMS assessments were not being completed during a recent internal audit and had started doing them again, but no further explanation was provided for the gap in monitoring.
Missing Bed-Hold and Transfer Notices for Hospitalized Residents
Penalty
Summary
The facility did not ensure that residents transferred to the hospital received written notice of the transfer and bed-hold information, including the reserve bed payment rate or policy. The facility policy titled "Bedhold Notice Upon Transfer" stated that residents and/or their representatives were to be given written notice at the time of transfer or within 24 hours for an emergency transfer, including the duration of the bed-hold policy, the reserved bed payment policy, and the facility’s return-to-bed procedures. The policy also stated that a signed and dated copy of the notice would be kept in the resident’s file. One resident, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction and type 2 diabetes mellitus with diabetic polyneuropathy, was hospitalized twice for nausea and vomiting. For the first hospitalization, the electronic record contained a bed-hold notice and transfer notice with the resident’s signature, but the notice did not specify any reserve bed payment rate, policy, or procedure detail. For the second hospitalization, the surveyor did not locate a bed-hold notice or transfer notice in the record, and the DON confirmed that no bed-hold notice was located for that transfer. A second resident, who had diagnoses including left above-the-knee amputation with phantom limb syndrome, type 2 diabetes mellitus, absence of the right toes, opioid dependence, major depressive disorder, and a history of tuberculosis, was transferred to the hospital for episodes of brown, coffee-ground-like emesis. The resident had intact cognition with a BIMS score of 15 and was their own person. The medical record did not contain a bed-hold or transfer notice for the hospital transfer, and staff stated the resident often refused to sign the notice; however, there was no progress note documenting a refusal on the transfer date. Surveyor review also found that the bed-hold/transfer notice form did not include the reserve bed payment rate/policy and procedure detail, and medical records staff stated copies of the forms were scanned into the chart and not provided to the resident or representative.
Delayed PASARR Level 2 Screening
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed as required for one resident reviewed. R50’s PASARR level 1 indicated suspected serious mental illness and the need for a level 2 screening, but the facility did not have a PASARR policy and procedure and did not complete the level 2 within 30 days of admission. R50 was admitted with diagnoses of post-traumatic stress disorder and depression, and later had generalized anxiety disorder added to the record. The resident’s physician orders also included Buspirone for generalized anxiety disorder, Fluoxetine for OCD/anxiety, monitoring for anti-psychotic side effects each shift, behavior monitoring each shift, non-pharmacological interventions each shift, and documentation of symptoms such as sadness, crying, tearfulness, and social isolation. R50’s PASARR level 2 was not submitted until almost 2 years after admission. Surveyor interviews with the DON and Director of SS showed differing explanations for the delay, including a statement that a new diagnosis or medication could trigger a PASARR 2 and later an explanation that an audit on 5/1/25 identified the generalized anxiety diagnosis added on 2/5/24. The surveyor stated the level 2 should have been submitted no later than 30 days after the admission date based on the PASARR level 1 and the admission diagnoses, and the DON acknowledged the error.
Failure to Provide Needed Nail Care and Urinal Assistance
Penalty
Summary
The facility did not ensure that a resident who was dependent with activities of daily living received the necessary services to maintain grooming and hygiene. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side and type 2 diabetes mellitus with diabetic polyneuropathy. The resident’s CAA documented extensive help with ADLs due to severely limited mobility, and the MDS showed impaired ROM on one side, need for assistance with toileting hygiene, dressing, personal hygiene, bed mobility, and dependence for sit-to-stand and bed-to-chair transfers. The resident also had care plans for mobility/self-care impairment and altered elimination, with interventions for nail care as needed, toileting assistance, and checking/changing every 2-3 hours and as needed. Survey observations showed the resident’s fingernails were extremely long on both hands, with the nails longer on the contracted right hand, and the resident stated the fingernails needed to be cut and had not been cut in a long time. Surveyors also repeatedly observed the resident’s urinal hanging on the side of the bed half-full over multiple observations. The care plan did not include interventions for urinal use or the intervals for urinal care. During interview, an LPN stated staff should empty a urinal after use or during 2-hour rounds if urine was noted in it, and that diabetic residents’ nails should be brought to the LPN’s attention for cutting. The DON was informed that the resident’s nails remained extremely long and the urinal remained full during repeated observations.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility did not ensure one resident with a diagnosis of PTSD received culturally competent, trauma informed care in accordance with professional standards of practice and the resident’s experiences and preferences. The resident had diagnoses including major depressive disorder, bipolar disorder, anxiety disorder, mild cognitive impairment, PTSD, hoarding disorder, alcohol abuse, and insomnia, and the annual MDS indicated intact cognition with a BIMS score of 15. The resident was their own person and did not have an activated power of attorney. A trauma informed care assessment completed by nursing documented the resident answered “No” to having experienced a traumatic event, despite psychiatric progress notes later documenting a rough childhood and abuse from the father and uncle, including mental/verbal, physical, and sexual abuse. Survey review found no person-centered care plan focused on the resident’s PTSD triggers or interventions, and the CNA Kardex also contained no documentation of possible PTSD triggers or interventions. The resident’s psychiatric nurse practitioner notes from February 2025 through August 2025 were reviewed, but the trauma history documented there was not reflected in the care plan or Kardex. Staff interviews showed they were not aware of the resident’s PTSD triggers or what events caused the PTSD. A CNA stated she was not aware the resident had a history of PTSD and did not know the triggers or interventions. An LPN stated PTSD triggers and interventions should be in the care plan and documented for staff awareness. The DON stated the resident should have had an admission trauma assessment and quarterly trauma assessments thereafter if PTSD history was identified, but was not sure why the resident was documented as “No” on the trauma assessment and acknowledged it should have been followed up. The DSS also stated the resident’s trauma history was not captured on the care plan and that no specific interventions had been developed to help cope with PTSD triggers.
Incomplete Bed Rail Assessment and Missing Orders, Consent, and Monitoring
Penalty
Summary
The facility did not comprehensively assess a resident before and after applying bed mobility devices. R40 was observed in bed with partial bilateral bed rails, but the medical record did not show any attempted alternatives, indication for use, or scheduled maintenance of the mobility devices. The report states that R40’s Bed Rail Assessment was incomplete and documented only the right bed rail, while bilateral rails were present in the room. R40 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, congestive heart failure, vascular disease, depression, and anxiety. The Bed Rail Assessment completed on 6/3/25 documented that R40 was non-ambulatory, had a history of falls, and had poor bed mobility or difficulty moving to a sitting position on the side of the bed. The assessment also showed no options were chosen for interventions such as lowering the bed, restorative care, frequent night monitoring, assisted toileting at night, or visual and verbal reminders to use the call bell. The assessment for the right side rail had no resident or responsible party signature or date, and no RN signature or date. The medical record also lacked a signed consent for mobility devices, a device evaluation for installation, a physician order for mobility devices, and a physician order for monitoring of potential residual side effects. During interview, the DON confirmed there was no physician order, device evaluation, consent, or monitoring taking place. The Maintenance Director stated there was no process in place for device evaluation, standard maintenance checks on bed rails, or reference to manufacturer guidelines, and the NHA stated there was no assessment form for the gap assessment.
Failure to Arrange Needed Dental and Oral Surgery Care
Penalty
Summary
The facility did not ensure that one resident reviewed for dental concerns received the necessary dental services. The resident, admitted with diagnoses of dysphagia, chronic respiratory failure, and COPD, told the surveyor that he had broken and missing teeth and had been told he could see the dentist, but no one from the facility had helped him with the concern. The surveyor observed broken and missing teeth in the resident’s mouth. The medical record showed a dental exam on 7/23/25 documenting that the resident had 13 teeth/roots present, had several teeth extracted the prior year, and was supposed to have another oral surgery appointment for additional extractions, with the facility staff needing to set up the oral surgery appointment. There was no evidence in the record that an oral surgery appointment had been made. When interviewed, the DON stated the resident had not been to the oral surgeon and no appointment had been made, and noted that transportation by stretcher may have been a barrier.
Incomplete Documentation for Hospital Transfer
Penalty
Summary
The facility did not ensure the medical record for one resident was accurate and complete according to accepted professional standards when the resident was transferred to a hospital. The resident was admitted with diagnoses of morbid obesity, chronic obstructive pulmonary disease, and type 2 diabetes, and the discharge MDS documented that the resident was discharged to the hospital. However, the nurses’ notes did not include documentation of any assessment related to the need to send the resident to the hospital, and the record did not identify the reason for the transfer or where the resident was transferred. During interview, the DON stated she understood the concern and had no information, and said she expected nurses to document an SBAR when a resident is discharged to the hospital.
CNA Did Not Complete Required Annual Training Hours
Penalty
Summary
The facility did not ensure that 1 of 4 sampled CNAs, CNA-JJ, completed the required annual 12 hours of educational training. The Facility Assessment Tool last updated 5/2025 stated that in-service training for nurse aides must be sufficient to ensure continuing competence and be no less than 12 hours per year. During interview and record review, the business office reported that one CNA hired on 8/8/23 had only 2.1 hours of training in the last year, and when the report was run again it showed 5.6 hours, still below the required 12 hours. The business office stated the facility performs monthly audits and that CNA-JJ must have been overlooked. The concern was discussed with the NHA and DON during the end of day meeting, and no additional information was provided as to why CNA-JJ did not receive the required continuing competence training.
Failure to Timely Report Abuse Allegations and a Fall With Fracture
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft to the state agency for 3 of 3 allegations reviewed. The deficiencies involved a resident with major depressive disorder and alcoholic cirrhosis who alleged verbal abuse by staff, a resident with multiple neurologic and psychiatric diagnoses and a legal guardian who sustained a fall with fracture, and a resident with depression and a history of TIA/cerebral infarction who alleged physical and verbal abuse by a CNA. Surveyor review and interviews showed the facility did not report these events within the required time frames, and in one case did not report the allegation to local or state agencies at all at the time of review. For the resident who alleged verbal abuse, the allegation was reported internally to the Director of Social Services the day after the incident, but the facility self-report was not sent to the state agency until several days later. The Director of Social Services was unable to explain why the report was not submitted within the required 2-hour time frame. The Nursing Home Administrator was also informed of the concern and did not provide additional information at that time. For the resident who fell and sustained nondisplaced fractures of the left sacral ala and right inferior pubic ramus, the hospital record documented that the resident tripped over a foot and fell after being sent to the hospital from the facility. Surveyor review did not locate a facility-reported incident for the fall, and the Nursing Home Administrator stated the fall resulting in serious bodily injury was not reported to proper authorities and was unsure why it was not reported. For the resident who alleged a CNA pushed her in the chest, surveyor review of the grievance and interviews showed the facility treated an earlier complaint as a privacy issue, while later statements from the resident and staff led the facility to recognize the matter as abuse. At the time of review, the allegations had not been timely reported to state or local agencies, and facility leadership acknowledged the reporting failure.
Incomplete Investigation of Abuse Allegations and a Fall With Fracture
Penalty
Summary
The facility did not ensure that allegations of abuse were thoroughly investigated for three residents. The report identifies an allegation of verbal abuse involving a resident with major depressive disorder and alcoholic cirrhosis, a fall with fracture involving a resident with multiple neurologic and psychiatric diagnoses and a legal guardian, and allegations of physical and verbal abuse involving a resident with depression and a history of cerebrovascular disease. In each case, survey review and staff interviews showed missing or incomplete investigative documentation. For the resident with the verbal abuse allegation, the facility self-reported an incident involving a staff member, but the investigation did not include interviews with additional residents regarding their safety or possible knowledge of the allegation. The Director of Social Services was unable to explain why those interviews were missing, and the Nursing Home Administrator did not provide additional information when the concern was raised. For the resident who sustained a fall with fracture, nursing documentation showed the resident was found on the floor beside an overturned wheelchair and was sent to the hospital. Hospital records documented nondisplaced fractures of the left sacral ala and right inferior pubic ramus after the resident tripped and fell. The facility’s fall investigation file contained only risk assessments, progress notes, and care plans, with no staff statements or documentation of when the resident was last checked or offered toileting assistance. The Director of Nursing stated the normal fall protocol previously included staff statements and a more thorough investigation, but no explanation was provided for why that did not occur for this fall. For the resident who alleged physical and verbal abuse by a CNA, the surveyor found conflicting and incomplete grievance and investigation records. One grievance described the CNA entering the room without knocking while the resident was naked, and another account documented the resident saying the CNA would not do anything for them. Later, the resident told surveyors that the CNA pushed them in the chest, while a separate statement documented that no one pushed them. The Director of Social Services acknowledged that important information was missing from the investigation packet, and the Nursing Home Administrator later stated the facility did not complete a thorough investigation for the allegations.
State Survey Binder Not Readily Accessible
Penalty
Summary
The facility did not ensure the most recent State Survey results were readily accessible to residents, family members, and legal representatives. The facility policy titled, Availability of Survey Results, stated that a readable copy of the most recent federal and/or state survey report and plan of correction would be maintained in a 3-ring binder in the main lobby and available for review without having to ask staff, with signs posted throughout the building identifying its location. The report stated this issue had the potential to affect all 85 residents who resided in the facility at the time of the survey. During the Resident Council meeting on 9/10/2025, residents in attendance stated they did not know where to view the state survey binder. After the meeting, the surveyor observed the wall where the binder was supposed to be located, and it was not there. When interviewed, the Nursing Home Administrator stated the binder had been placed there but kept disappearing, and that it had been carried out of the building in June or July and again in August. On 9/15/2025, the NHA again stated the binder was not readily available because it kept getting stolen, and no additional information was provided as to why the binder was not accessible for review.
Failure to Accommodate Resident Food Preferences and Heating Requests
Penalty
Summary
A deficiency occurred when the facility failed to provide reasonable accommodations for a resident who refused to eat facility-prepared food and relied on meals brought in by family. The resident, who was cognitively intact and had diagnoses including lupus erythematosus, arthritis, protein-calorie malnutrition, and major depressive disorder, stored her food in her room refrigerator and requested that staff heat her meals. The facility was aware of her preferences, as documented in her care plan, but did not consistently meet her requests to have food heated, particularly after the unit microwave broke and staff were instructed to use the kitchen instead. On a specific occasion, the resident requested that a CNA ask a dietary aide to heat up a can of chili. The dietary aide refused, stating she was done cooking and would not do it, despite the resident referencing prior approval from the dietary manager. The dietary aide later acknowledged the refusal, explaining it was during kitchen clean-up and she was already heating food for another resident. The resident reported feeling uncomfortable and hesitant to request warm meals after this incident, and staff interviews confirmed the refusal and the lack of a consistent process for accommodating such requests. The facility's policy on resident rights emphasizes self-determination and the right to make choices about significant aspects of life in the facility. However, the resident's need for her food to be heated was not accommodated in a timely or consistent manner, and limitations were placed on when her food could be heated. The incident was not promptly communicated to the nursing home administrator, who later acknowledged the failure to meet the resident's needs and the unreasonableness of restricting food heating to certain hours.
Failure to Prevent Elopement and Accidents Due to Inadequate Supervision and Device Use
Penalty
Summary
The facility failed to ensure adequate supervision and the use of assistance devices to prevent elopements and accidents for two residents reviewed for elopement and falls. One resident with a history of cerebrovascular disease, moyamoya disease, and vascular dementia was found outside the facility in the early morning hours, having fallen and sustained an abrasion. The incident was not thoroughly investigated to determine the root cause of the fall or how the resident eloped from the building. Documentation was unclear regarding the functionality of the door alarms at the time, and there was no evidence that an elopement care plan was initiated following the event. Additionally, the resident's care plan was not updated to address wandering or elopement risks, despite subsequent documentation of wandering behaviors and agitation. A second elopement occurred when the same resident was discovered missing from the facility in the middle of the night and was later found by police over a mile away, sitting at a street intersection. There was no investigation into this elopement, no assessment of the resident upon return, and no revision of the care plan to increase supervision or address the incident. Staff interviews revealed confusion about the resident's risk status, the use and location of elopement binders, and the procedures for monitoring residents at risk for elopement. The facility's documentation did not reflect consistent or timely assessment, monitoring, or communication regarding the resident's behaviors and risks. Additionally, another resident experienced a fall from bed due to the bed wheels not being locked, despite a care plan intervention requiring the wheels to be locked during transfers. Observations confirmed that this intervention was not in place at the time of the fall. The facility's failure to supervise residents adequately, ensure the functionality of safety devices such as door alarms, and conduct thorough investigations into accidents and elopements resulted in a finding of immediate jeopardy. The lack of timely and comprehensive documentation, assessment, and care plan updates contributed to the ongoing deficient practice.
Failure to Immediately Report and Respond to Verbal Abuse by CNA
Penalty
Summary
A Certified Nursing Assistant (CNA) was witnessed verbally abusing a resident with moderate cognitive impairment by responding to the resident's greeting with profane and derogatory language. The incident was observed by a receptionist, who did not immediately report the abuse to the Nursing Home Administrator or Social Worker as required by facility policy. Instead, the receptionist wrote a note and placed it under the Social Worker's door, which was not discovered until the following day. As a result, the CNA continued to work the remainder of their shift on the same unit as the resident, potentially exposing the resident and others to further abuse. The facility's policy mandates immediate reporting and investigation of abuse allegations, as well as protective measures for residents. However, the delay in reporting led to a failure to promptly initiate an investigation and to remove the alleged perpetrator from resident care duties. The investigation was not started until the day after the incident, and interviews to rule out further abuse were not conducted with all residents assigned to the CNA on the day of the incident. The resident involved recalled the incident but reported no adverse outcome.
Failure to Immediately Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure that allegations of verbal abuse and misappropriation involving two residents were immediately reported to the Nursing Home Administrator (NHA) or Social Worker, as required by facility policy. In one instance, a resident with moderate cognitive impairment was verbally abused by a CNA, an incident witnessed by the facility receptionist. Instead of immediately notifying the NHA or Social Worker, the receptionist wrote a note and placed it under the Social Worker’s door, resulting in a delay in reporting. The Social Worker did not become aware of the incident until the following day, and the CNA continued to work on the resident’s unit for the remainder of the shift before being suspended the next day. Additionally, another resident’s allegation of misappropriation of money and property was not reported to the NHA or Social Worker, which also led to a delay in reporting to the State Agency. The facility’s policy requires immediate investigation and reporting of all alleged violations to the Administrator and appropriate authorities within specific timeframes, but these procedures were not followed in these cases. The deficiencies were identified through interviews and record reviews conducted by surveyors.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the well-being of residents. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Insufficient Qualified Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to manage the food and nutrition services. The Dietary Director (DD) was not certified as a food service manager or dietary manager and was not currently enrolled in a certification program, despite attempts to re-enroll. The DD held a baccalaureate degree in marketing, which does not meet the regulatory requirements for the position. The Registered Dietitian (RD) was contracted to provide oversight but was not on-site full time, working only one to two days per week at the facility and the remainder remotely. The facility did not have a copy of the current contract with the RD readily available, and the contract itself was not fully executed with all required dates. The deficiency affected all 91 residents in the facility, as the DD did not meet the qualifications required to serve as the director of food and nutrition services, and the RD did not provide full-time on-site supervision. The facility had submitted a waiver request to the state agency for the DD's lack of certification, but at the time of the survey, the DD was not actively enrolled in a certification program and had not received responses from the school. The DON and NHA acknowledged these concerns during interviews, and no additional information was provided to demonstrate compliance with staffing or qualification requirements for the food and nutrition service.
Failure to Maintain Required Staff Training and Competency Documentation
Penalty
Summary
The facility failed to implement and maintain an effective training program for all new and existing staff members, as required by its own Facility Assessment Tool and federal regulations. Specifically, for five Certified Nursing Assistants (CNAs), there was no evidence of completed annual competency reviews or documentation that each had received at least 12 hours of required in-service training annually from their date of hire. The facility's assessment outlined that staff training, education, and competency checks should be provided upon hire, monthly, annually, or as needed based on resident needs and staff performance, covering topics such as resident rights, abuse prevention, dementia care, and HIPAA compliance. During the survey, the Director of Nursing (DON) was unable to provide records of annual competency reviews or proof of the required annual training hours for the five CNAs in question. The Nursing Home Administrator (NHA) also confirmed the absence of this documentation. No additional information or evidence was provided to demonstrate compliance with the training and competency requirements for these staff members.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 720 citations issued within 25 miles in the last 12 months — including the 15 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 Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Glendale West | 0.9 mi | ★★★★★ | 4 | 0 |
| Eastcastle Pl Bradford Ter Conv Ctr | 4.5 mi | ★★★★★ | 16 | 0 |
| Milwaukee Catholic Home | 4.5 mi | ★★★★★ | 0 | 0 |
| Bradley Estates Nursing And Rehab Llc | 4.6 mi | ★★★★★ | 40 | 0 |
| Edenbrook Lakeside | 4.7 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.