Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beloit Health And Rehabilitation Center during CMS and state inspections, most recent first.
Food handling and hand hygiene practices were not followed during meal preparation and dining assistance. Staff were observed in the kitchen without hair restraints, a cook touched ready-to-eat food after contaminating gloves by touching clothing, and a CNA assisted multiple residents with meals without washing or sanitizing hands between residents. The DM, FSD, and ADON/IP confirmed the expected practices for hair restraints, glove use, and hand hygiene.
Improper Disposal of Garbage and Refuse: During a kitchen walk-through, the surveyor observed garbage on the ground next to the dumpsters, including cardboard, food wrappers, and used gloves. The DM stated garbage should not be left on the ground and that everyone is responsible for picking it up, and the NHA stated garbage should be put in the dumpster.
A resident with cancer and psychiatric diagnoses had a 7.4% wt loss in 30 days and was identified by the RD for a scheduled HS snack to support calorie intake. Although the RD recommended the snack to help meet nutritional needs, the order was not entered for 8 days, and the NHA acknowledged it should have started sooner.
A resident with stroke-related weakness, DM2, depression, and HTN reported trying to schedule a PCP visit and not having been seen in a while. Surveyors reviewed the resident’s chart and EHR and could not find physician progress notes or visit documentation. The receptionist was unaware of the request, and the DON provided only one older visit note and stated the facility is responsible for obtaining physician notes and that the record is incomplete if they are missing.
Failure to Provide Ordered Ground Meat Texture: A resident with encephalopathy, adult failure to thrive, and unspecified dementia had an order for a mechanical soft diet with ground meat, but was observed receiving meals that were not prepared to that texture. Staff identified the meat as soft, diced, or not ground, while the FSM stated the turkey was diced and not appropriate for the resident’s ordered diet.
Arbitration Agreement Not Adequately Explained Before Signature: A resident with severe cognitive impairment and dementia had a signed arbitration agreement in the admission packet, but the resident representatives said it was not fully explained and they did not understand they were waiving use of the judicial system. The RCC also misunderstood the agreement, incorrectly describing the dispute process and rescission period, while the NHA confirmed the agreement was presented during admission.
A facility failed to include accurate potential financial liability information when issuing SNFABNs for three residents whose Medicare A coverage was ending. The policy required updated room and therapy rate sheets to be issued with the ABN, but the BOM stated the rates were mailed without resident names, were not aware they needed to be attached, and had no documentation supporting verbal notice; the NHA stated the SNFABN should include room and therapy costs or chart documentation if not provided.
A resident with schizophrenia missed multiple doses of prescribed Seroquel over several days due to the medication not being available, and staff did not notify the physician or document required actions. Despite facility policy and available contingency supply, nursing staff failed to administer the medication, notify the provider, or document assessments and pharmacy contacts as required.
A resident with multiple chronic conditions and non-pressure wounds did not have wound care treatments completed or documented on several occasions, as shown by blank entries and missing progress notes in the TAR. After returning from a hospital stay, the resident also did not receive a full wound assessment, contrary to facility policy and staff expectations.
A resident did not receive pressure ulcer care as ordered, with multiple missed and undocumented wound treatments to the sacrum and bilateral ischial tuberosities. Nursing staff confirmed that blank entries on the TAR indicated treatments were not completed, and there were no progress notes explaining the omissions. This resulted in a failure to provide care consistent with professional standards and facility policy.
A resident was observed vaping inside the facility on two occasions, in violation of the facility's smoking policy. Despite these incidents, the care plan was not updated, no new smoking assessment was completed, and the resident retained access to vaping supplies. Facility leadership confirmed that required reassessment and care plan revisions were not performed.
A resident with schizophrenia was not given their prescribed Seroquel for several days, despite facility policy requiring staff to use contingency supplies, notify the pharmacy and physician, and document actions taken. Nursing notes showed repeated missed doses, and interviews confirmed that required notifications and assessments were not documented or completed.
A resident with Type 2 Diabetes Mellitus did not receive their scheduled insulin dose, leading to acute hyperglycemia and hospitalization. The facility failed to administer the insulin as ordered and did not have blood glucose monitoring in place. Interviews with staff confirmed the medication was not signed out on the MAR, and the DON acknowledged the oversight, which could have potentially prevented the hospitalization.
The facility failed to follow its Antibiotic Stewardship Program, leading to inappropriate antibiotic prescriptions for three residents. One resident with a history of antibiotic resistance received antibiotics for asymptomatic bacteremia five times, resulting in actual harm. Another resident was treated for a UTI without meeting criteria, and a third resident received antibiotics for an acute kidney injury without justification. The facility did not adequately review urine culture reports or educate physicians on proper antibiotic use.
The facility failed to serve meals at times in accordance with residents' preferences, affecting all 58 residents. A resident reported receiving lunch and dinner significantly later than scheduled, while another expressed distress over consistently late meals. A third resident noted that late breakfast delivery impacted his ability to eat lunch. The Nutrition Services Director cited staffing challenges as the cause.
The facility inaccurately reported staffing data to CMS, triggering deficiencies for low weekend staffing over five fiscal quarters. Interviews revealed a lack of understanding among staff about the facility's staffing assessments and reporting processes. Despite managerial assistance on weekends, these hours were not included in the PBJ reports, leading to the deficiency.
The facility failed to maintain an effective infection prevention and control program, with outdated policies and inadequate contact tracing and testing during a COVID-19 outbreak. Contact tracing was not completed for some residents, and testing was delayed for others, potentially contributing to the virus's spread. Additionally, breaches in infection control techniques were observed during resident care, indicating a lack of proper training and adherence to protocols.
The facility failed to maintain a safe, clean, and homelike environment for residents, with issues such as unclean floors, broken furniture, and room disrepair. Staffing and communication problems contributed to these deficiencies, as cleaning was not performed due to a housekeeper's departure, and maintenance issues were not reported or addressed promptly. Residents were left with inadequate living conditions, impacting their comfort and safety.
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in personal hygiene and grooming. A resident did not receive scheduled showers, another did not receive recommended oral care, and a third was inaccurately documented as independent in oral hygiene. Additionally, a resident's long and dirty fingernails indicated a lack of grooming assistance.
A facility failed to provide adequate nursing staff, resulting in long wait times for resident assistance and unmet care needs. Residents reported waiting over an hour for call lights to be answered, especially on weekends. Staff interviews revealed that CNAs were responsible for more residents than the facility's stated ratio, leading to incomplete care tasks. The DON acknowledged staffing challenges and the lack of call light audit documentation.
A resident's grievances regarding Hoyer lift transfers and a staff interaction were not documented or resolved, violating the facility's grievance policy. The resident experienced pain during transfers due to an inadequate lift, and a rude comment from a CNA was not addressed. Despite staff awareness, no formal grievance process was followed.
A resident admitted with anoxic brain damage did not receive a baseline care plan review within 48 hours, as required by facility policy. Interviews with staff revealed that the initial care plan is typically discussed at a care conference held within 72 hours, rather than the mandated 48-hour period. The DON acknowledged the expectation for timely sharing of the care plan.
A facility failed to create a comprehensive person-centered care plan for a resident with hemiplegia and cognitive impairment. The resident expressed pain when staff mishandled her left arm, a preference not documented in her care plan. Despite the resident's regular requests, a CNA continued to handle the arm improperly, leading to discomfort. The DON acknowledged the need for the resident's preferences to be included in the care plan.
The facility failed to involve two residents in the care planning process and did not update a resident's care plan to reflect a change in code status. One resident did not have quarterly care plan meetings, while another's care plan was not updated to show a DNR status despite a signed form and hospice admission.
A resident's medical orders were delayed in transcription for two days, leading to a lapse in timely treatment. The orders included nutritional supplements, dressing changes, surgery, an antibiotic, and a lipid profile. Facility staff confirmed that orders should be transcribed on the day received, but this did not occur, although no adverse effects were reported.
The facility failed to provide consistent wound care for residents with pressure injuries, as treatments were not completed as ordered for three residents. One resident with multiple stage 4 pressure ulcers frequently missed treatments due to leaving the facility, while another with hemiplegia and diabetes had several missed treatments documented. A third resident with paraplegia and lung cancer also experienced missed treatments. Staff interviews confirmed that a blank in the TAR indicated a missed treatment, contributing to the deficiency.
A facility failed to ensure a safe environment for three residents. One resident smoked without an assessment or care plan, another's electric wheelchair was improperly charged in their room, and a third used an electric scooter without a prior safety assessment. Staff were aware of these issues but did not adhere to facility policies.
A resident in a LTC facility had a lidocaine patch left on overnight, contrary to the facility's medication administration policy. The LPN discovered the error during a medication session, noting the patch lacked a date or initials. The facility was out of the prescribed 5% patch, leading to a switch to a 4% patch without proper documentation of the overnight error. The DON recognized this as a medication error.
A facility was found to have a medication error rate of 10.71%, exceeding the acceptable 5% threshold. Errors involved incorrect dosing and administration for two residents. One resident received an incorrect dose of Sevelamer, while another was nearly given another resident's medication and had issues with a lidocaine patch application. These errors were observed by a surveyor during a medication pass task.
The facility failed to properly label and store medications, as observed during a survey. Expired liquid Tylenol was found in the medication room, and an open insulin vial lacked an open date. On a medication cart, artificial tears were improperly labeled, missing full resident names and open dates. Staff confirmed these medications should have been labeled according to facility guidelines.
The facility did not ensure food was served at palatable temperatures, as reported by two residents and confirmed by a test tray. A resident with diabetes and heart disease reported cold food, while another with mild cognitive impairment noted lukewarm meals. A test tray showed food temperatures below standard, with mushy noodles. The Nutrition Services Director cited issues with staff leaving warming boxes open.
The facility failed to properly label and manage food items in the medication room refrigerator, resulting in expired thickened liquids and chocolate milk being stored. Despite policies requiring labeling and timely disposal, staff interviews revealed a lack of adherence to these standards, leading to expired items not being removed.
Food Handling and Hand Hygiene Lapses in Kitchen and Dining Room
Penalty
Summary
The facility did not maintain a safe and sanitary environment in which food was prepared, stored, distributed, and served. During observation in the kitchen, staff were seen without hair restraints, and the Dietary Manager confirmed that staff should wear hair restraints any time they are in the kitchen. In another observation, Cook E handled ready-to-eat food after touching the waistband of pants with the same gloved hand, and the Food Services Director and the Assistant Director of Nursing/Infection Preventionist both stated that gloves are contaminated after touching clothing and should not be used to touch ready-to-eat food. During dining room observations, CNA M assisted multiple residents with meals without washing or sanitizing hands between residents. CNA M was observed cleaning a resident’s glasses, helping one resident with a fork, then assisting another resident with his fork and later handing a cup back to the first resident, and opening cake for a third resident, all without hand hygiene between tasks. CNA M later stated she should have washed or sanitized her hands after assisting each resident, and the NHA, DON, and ADON confirmed that hand hygiene should be performed before doing anything with food and between residents when assisting in the dining room.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Garbage and refuse were not disposed of properly at the facility. During an initial walk-through of the kitchen on 1/27/26 at 9:44 AM, the surveyor observed garbage on the ground next to the facility dumpsters, including cardboard, food wrappers, and used gloves. The facility policy, Disposal of Garbage and Refuse, revised in 3/2025, states that the facility shall properly dispose of kitchen garbage and refuse and that dumpsters shall be emptied according to the facility contract. The Dietary Manager stated that garbage should not be left on the ground and that everyone is responsible for picking up garbage. On 1/28/26 at 1:10 PM, the Nursing Home Administrator stated that garbage should be picked up and put in the dumpster and indicated understanding of the concern.
Delayed implementation of bedtime snack order for resident with weight loss
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not ensured for one of four residents reviewed, R12, who triggered for a significant weight change after losing 7.4% of body weight in 30 days. R12 was admitted with diagnoses including cancer, bipolar disorder, and panic disorder. The care plan identified nutritional problems or potential nutritional problems related to cancer and a recent hospitalization, and stated the resident would maintain adequate nutritional status with no significant weight changes and intake of at least 50% of at least 3 meals daily. The Registered Dietician documented that R12 was on a regular diet and averaging 50-100% of meals, and recommended a scheduled snack of choice at bedtime to help meet calorie needs. The Registered Dietician made the snack recommendation on 1/20/26, but the order for a bedtime snack of choice was not entered until 1/28/26. The facility's policy stated that it provides care and services to ensure residents maintain acceptable nutritional status and that a systematic approach includes developing and consistently implementing pertinent approaches. On interview, the Nursing Home Administrator stated the recommendation did not start until 1/28/26 and that it should have been started sooner.
Missing physician visit documentation for a resident
Penalty
Summary
The facility did not ensure physician progress notes were maintained in the resident’s physical chart or EHR for one of three supplemental residents reviewed, R61. R61, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, type 2 diabetes mellitus, depression, and hypertension, had a most recent MDS dated 1/27/26 showing a BIMS score of 15 out of 15, indicating cognitive intactness. During a resident group meeting on 1/28/26, R61 stated they had been trying to schedule an appointment with their PCP and had not had an appointment in a while. Surveyors reviewed the physical chart and EHR the same day and were unable to locate documentation showing that R61’s PCP or delegate had seen them. The facility’s receptionist, who handled medical records and scheduling, stated that when a resident wants an appointment, the nurse communicates the request and the appointment is then scheduled, but she was unaware of R61’s request and said R61’s PCP comes to the facility on Fridays. The DON later provided only a visit note dated 6/4/25 and stated that was the documentation received for R61’s last visit. The DON stated residents should be seen every 30 days for the first 90 days and at least every 60 days thereafter, and agreed R61 should be seen more regularly. The DON also stated the facility is responsible for obtaining physician visit notes and that if the notes are not in the medical record, the record is not complete.
Failure to Provide Ordered Ground Meat Texture
Penalty
Summary
The facility did not ensure that each resident received food prepared in a form designed to meet individual needs for 1 of 4 residents reviewed for nutrition. R40 had physician orders for a regular diet with mechanical soft and ground meat texture, and the facility’s Therapeutic Diet Orders policy stated that residents are to receive foods in the appropriate form as prescribed and that mechanically altered diets include ground meat. R40 was admitted with diagnoses including encephalopathy, adult failure to thrive, and unspecified dementia. During observation, R40 was seen eating meals that did not match the ordered ground meat texture. On 1/27/26, R40 was observed with chicken fajitas served as thick strips in a soft shell tortilla, along with rice, beans, and cake, and was eating independently with no teeth and occasionally spitting out bites of food. On 1/28/26, R40 was served turkey cut into cubes in gravy over bread with mashed potatoes and sliced carrots, and the meal ticket identified the entree as a mechanical ground open faced turkey sandwich. CNA H stated the meat did not appear ground and would check, while the BOM stated staff should serve the right meal to the right person. The cook stated the meat was considered ground because it was soft, but the FSM stated the turkey was diced, not ground, and that diced was not appropriate for R40. The FSM explained the turkey needed to be ground in the food processor to a taco meat consistency, and the NHA stated staff were expected to follow the proper diet and serve foods according to physician orders.
Arbitration Agreement Not Adequately Explained Before Signature
Penalty
Summary
The facility did not implement an established process to assess a resident’s cognitive ability to understand a binding arbitration agreement before obtaining a signature, and it did not ensure the staff responsible for presenting the agreement could thoroughly explain it. The deficiency involved one sampled resident, R44, whose record showed diagnoses including cerebral infarction, type 2 diabetes mellitus, and unspecified dementia. R44’s most recent MDS indicated severely impaired cognition with a BIMS score of 3 out of 15. R44’s admission packet contained a signed arbitration agreement dated 12/9/25. The packet included 114 pages, with 8 pages devoted to the arbitration agreement and a signature line on page 12. The agreement stated that signing was not a condition of admission, that the resident had the right to consult with an attorney, family, or friends, and that disputes would be resolved exclusively by binding arbitration rather than a lawsuit or judicial process, except as allowed by law. It also stated the agreement could be rescinded by written notice within 30 days of signature. During interviews, RR K stated she was concerned that the arbitration agreement had been signed during admission paperwork without being fully explained and said she would not have signed it if she had understood she was giving up the ability to use the judicial system to resolve disputes. RR/POA J stated she was unaware whether she had signed an arbitration agreement and did not know what arbitration meant; after the surveyor reviewed the document with her, she said she would never have signed it if she had understood it. RCC L incorrectly described arbitration as settling disputes in county circuit court, stated there was no rescission time frame, and said once signed it was in effect, despite the agreement’s 30-day rescission language. The NHA stated residents and/or representatives were presented with the agreement during admission and acknowledged that RCC L should be able to explain it and know the time limits associated with it.
SNFABNs Lacked Accurate Financial Liability Information
Penalty
Summary
The facility did not include accurate potential financial liability for residents whose Medicare coverage was ending when issuing Skilled Nursing Facility Advance Beneficiary Notices (SNFABNs) for 3 of 3 residents reviewed: R43, R54, and R72. Each of these residents was receiving Medicare A benefits, and the SNFABNs issued for them did not provide the accurate room and therapy rate information referenced in the facility’s policy and on the form’s estimated cost section. The facility policy titled Policy and Procedure: Advanced Beneficiary Notice dated 2/1/22 states that when services are no longer necessary, Social Services issues Room and Board ABNs and the Business Office Manager provides updated room rate and therapy rate sheets to be issued with the ABN. During interview, the Business Office Manager stated that Social Services handles the SNFABNs, that room rates are mailed to families without names on them, that they were not aware the room and therapy rates needed to be issued with the SNFABNs, and that there was no documentation to support verbal notification. The Nursing Home Administrator stated that the SNFABN should contain the cost of room and therapy and that documentation would be expected in the resident’s chart if a paper copy were not provided.
Failure to Notify Physician and Administer Antipsychotic Medication
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify and consult with a physician after a resident missed multiple doses of a prescribed antipsychotic medication, Seroquel, over several days. The resident, who had a diagnosis of schizophrenia, had physician orders for Seroquel to be administered three times daily. Nursing progress notes repeatedly documented that the medication was not available in the medication cart and was either on order or awaiting delivery for an extended period, spanning from 12/21/24 through 12/30/24. Despite these ongoing missed doses, there was no documentation that the resident's physician was notified of the missed medication, as required by facility policy. Interviews with nursing staff, including LPNs, RNs, the ADON, and the DON, revealed that facility policy and staff expectations were to check the contingency medication supply, contact the pharmacy for stat delivery, and notify the physician when a medication was unavailable. Staff also indicated that these actions, as well as any assessments related to missed medications, should be documented in the resident's medical record. However, the surveyor found no evidence in the record that the physician was notified, the pharmacy was contacted for stat delivery, or that any assessments were completed regarding the missed Seroquel doses for the resident during the period in question. Additionally, the facility's contingency medication supply was found to contain Seroquel 25 mg, which could have been used to prevent missed doses. Despite this, the medication was not administered, and the required notifications and documentation were not completed. The facility's own policies on notification of changes and medication error reporting were not followed, resulting in a failure to ensure timely physician consultation and appropriate documentation when the resident did not receive their prescribed medication.
Failure to Complete and Document Wound Care and Assessment
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including metabolic encephalopathy, type 2 diabetes mellitus, cellulitis, open wounds to both lower extremities and right foot, peripheral vascular disease, and congestive heart failure, did not receive wound care in accordance with physician orders and facility policy. The Treatment Administration Record (TAR) for this resident showed blank entries on specific dates, indicating that wound care treatments were not completed or documented. On one occasion, a code indicating 'other/see nurse's notes' was used, but no corresponding nurse's note was found to explain the omission. Multiple staff interviews confirmed that a blank TAR entry means the treatment was not completed, and a code requires a progress note, which was missing. Additionally, after the resident returned from a hospital stay, a full assessment of the resident's non-pressure wounds was not completed as required. The admission/readmission evaluation documented the presence of multiple open areas and significant edema, but staff, including the Assistant Director of Nursing and Director of Nursing, acknowledged that a comprehensive wound assessment should have been performed upon readmission. These actions and omissions were not in accordance with professional standards of practice, the resident's care plan, or facility policy.
Failure to Provide and Document Pressure Ulcer Care as Ordered
Penalty
Summary
The facility failed to ensure that a resident received pressure ulcer care in accordance with professional standards and physician orders, as evidenced by multiple missed and undocumented wound treatments. The facility's policy requires that wound care be provided as ordered, with all treatments documented on the Treatment Administration Record (TAR) or in the electronic health record. For the resident in question, the TAR showed numerous blank entries for both sacral and bilateral ischial tuberosity wounds, indicating that wound care was not completed or not documented as completed on several occasions over a two-month period. Interviews with nursing staff, including RNs, LPNs, the Assistant Director of Nursing/Wound Nurse, and the Director of Nursing, confirmed that a blank TAR entry means the treatment was not completed, and that a specific code (the number 4) would indicate a progress note explaining why a treatment was missed. In this case, there were multiple dates with blank TAR entries and no corresponding progress notes, confirming that wound care was not provided or not documented as required. The resident had orders for specific wound care regimens, including cleansing with Vashe wound cleanser, application of skin prep, use of hydrofera blue classic and other dressings, and securing with various tapes and pads. Despite these orders, the TAR indicated that treatments to the sacrum were not documented as completed 26 times, and treatments to the bilateral ischial tuberosities were not documented as completed 11 times. This lack of documentation and completion of wound care represents a failure to provide care consistent with professional standards and the facility's own policies.
Failure to Update Care Plan and Supervision After Resident Vaping Incidents
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident who was observed vaping inside the facility, contrary to the established smoking policy. The resident's care plan allowed for unsupervised smoking, and their smoking supplies were kept on their person. Despite two documented incidents where the resident was found vaping inside the facility, including one instance where the resident was educated about the policy but did not comply, no new smoking assessment was completed, and the care plan was not updated to address the non-compliance. Facility policy required that electronic cigarettes be used only in designated smoking areas and that a safe smoking assessment be completed for all residents using e-cigarettes. The policy also stated that the care plan should be revised to include additional safety measures if a resident did not abide by the smoking policy. Interviews with the ADON and DON confirmed that appropriate reassessment and care plan updates were not performed following the incidents, and the resident continued to have access to their vaping supplies.
Failure to Provide Prescribed Antipsychotic Medication and Follow Medication Error Protocols
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of schizophrenia was not provided with their prescribed Seroquel (an antipsychotic medication) for several days. The physician's orders specified that the resident was to receive Seroquel 25 mg at three different times daily. However, nursing progress notes repeatedly documented that the medication was not available in the medication cart and was on order or awaiting delivery over a period spanning multiple days. There was no documentation indicating that the medication was administered during this time. Interviews with nursing staff, including LPNs, RNs, the ADON, and the DON, revealed that facility policy requires staff to check the contingency medication supply, contact the pharmacy for stat delivery, and notify the physician when a medication is unavailable. Staff also indicated that daily assessments should be completed and documented, and that missed medications constitute a medication error requiring risk management review. Despite these protocols, there was no evidence in the medical record that the pharmacy or physician was notified, or that assessments were completed for the missed doses of Seroquel. Additionally, the surveyor confirmed that the facility's contingency supply did contain Seroquel 25 mg, which could have been used to administer the medication. The lack of documentation and failure to follow established procedures resulted in the resident missing multiple doses of a critical medication, with no evidence of appropriate follow-up or communication as required by facility policy.
Failure to Administer Insulin Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the case of a resident with Type 2 Diabetes Mellitus who did not receive their scheduled insulin dose. The resident was admitted to the facility with a history of hyperglycemia and had a physician's order for insulin glargine to be administered once daily in the morning. However, on the morning of 7/24/24, the insulin was not administered, and there were no physician orders for blood glucose monitoring in place. This oversight led to the resident experiencing acute hyperglycemia, resulting in hospitalization and treatment with an insulin drip. Interviews with facility staff, including LPNs and the DON, revealed that the medication was not signed out on the MAR, indicating it was not administered. Staff acknowledged that blood glucose monitoring should have been ordered and conducted for a new admission with diabetes. The DON confirmed that the insulin was not given and that the lack of administration could have potentially prevented the hospitalization. The NP also indicated that regular blood glucose monitoring and the administration of the insulin could have prevented the need for hospitalization.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program, resulting in inappropriate antibiotic prescriptions for three residents. Resident R16, who has a history of antibiotic resistance, was prescribed antibiotics for asymptomatic bacteremia on five occasions between March and July 2024, despite not meeting the criteria for treatment. The facility did not adequately review R16's urine culture and sensitivity reports, leading to the administration of antibiotics to which R16 had developed resistance. This oversight resulted in actual harm to R16, as indicated by the severity level 3 citation. Resident R34 was prescribed antibiotics twice in July 2024 for a urinary tract infection (UTI) without meeting the necessary criteria. The urine culture and sensitivity report for R34 indicated mixed flora, suggesting a contaminated sample, yet the facility proceeded with antibiotic treatment without obtaining a recollection of urine as recommended. This action was cited at severity level 2, indicating the potential for more than minimal harm. Resident R612 was prescribed antibiotics for an acute kidney injury, despite not meeting the criteria for such treatment. The urine culture and sensitivity report showed mixed flora, and the physician later discontinued the antibiotic order after realizing the resident did not have a UTI. This incident was also cited at severity level 2. The Director of Nursing acknowledged the facility's failure to follow the antibiotic stewardship protocol and the lack of education provided to prescribing physicians regarding the treatment of asymptomatic bacteriuria.
Late Meal Service in LTC Facility
Penalty
Summary
The facility failed to ensure that meals and snacks were served at times in accordance with residents' needs, preferences, and requests. This deficiency was observed to potentially affect all 58 residents in the facility. Specific residents, including R8, R41, and R35, expressed concerns about meals being served over an hour after the scheduled times. Surveyors observed meals being served 1 to 1.5 hours late, with breakfast scheduled for 7:45 AM, lunch for 11:45 AM, and dinner for 4:45 PM. The facility's policy on meal frequency was not adhered to, as evidenced by the late meal service. Resident R8, who is cognitively intact, reported receiving lunch after 1:00 PM and dinner after 6:00 PM, contrary to her preference for meals at specific times. R41, with mild cognitive impairment, also reported that meals were consistently late, causing distress. R35, who has mild cognitive impairment and Parkinson's, noted that late breakfast delivery affected his ability to eat lunch due to the meals being too close together. The Nutrition Services Director acknowledged the issue, attributing it to staffing challenges, including new staff turnover and a cook still learning the routine.
Inaccurate Staffing Data Reporting to CMS
Penalty
Summary
The facility failed to ensure accurate reporting of mandatory staffing information to the Centers for Medicare & Medicaid Services (CMS) through the Payroll Based Journal (PBJ) system. This deficiency was identified over five fiscal year quarters, from April 2023 to June 2024, where the facility's weekend staffing data was consistently reported as excessively low. The facility's policy manual requires the submission of complete and accurate staffing information, including agency and contract staff, based on payroll and other verifiable data. However, the PBJ Staffing Data Reports for these quarters indicated that the submitted weekend staffing data was insufficient, triggering a deficiency for excessively low weekend staffing. Interviews with facility staff revealed a lack of understanding and communication regarding staffing assessments and reporting. Scheduler E, responsible for staffing according to census, was unaware of the facility assessment and did not understand why the facility was triggering for low staffing. The MDS Coordinator indicated that the facility assessment hours were historical and reviewed by corporate, while the Director of Nursing acknowledged that June was particularly challenging for weekend staffing. Despite having department heads assist on weekends, these hours were not reflected in the PBJ staffing numbers, contributing to the inaccurate reporting.
Inadequate Infection Control and COVID-19 Management
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by outdated policies and inadequate contact tracing and testing during a COVID-19 outbreak. The facility's infection prevention and control policies had not been reviewed annually, as required. During a COVID-19 outbreak in March 2024, the facility did not complete contact tracing for the first resident who tested positive, R613, and another resident, R614, who was exposed during a tornado drill. Additionally, the facility did not conduct timely COVID-19 testing for several residents who were exposed to the virus, including R8, R12, R13, R14, R26, R28, R41, R43, R47, R618, and R619. The facility's failure to adhere to its own policies and procedures for infection control was further demonstrated by the improper handling of a COVID-19 outbreak. The outbreak documentation revealed that contact tracing was not completed for R616, who was noted to have been in the main dining room for meals, contrary to the facility's assumption that she stayed in her room. Testing for exposed residents was not conducted according to the facility's policy, resulting in delayed testing for several residents, which could have contributed to the spread of the virus within the facility. Additionally, breaches in infection control techniques were observed during the care of R35. A CNA was seen placing clean washcloths on the edge of a potentially contaminated sink before using them for resident care. The CNA also used a gloved hand to remove zinc oxide from a container and applied it to different areas of the resident's body without changing gloves, which could lead to cross-contamination. These actions indicate a lack of proper training and adherence to infection control protocols among staff.
Deficiencies in Cleanliness and Maintenance in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed by surveyors. In the case of two residents, their rooms were found to have unclean floors with visible dirt, which was confirmed by a housekeeper who admitted that the floors were not cleaned due to a miscommunication and staffing issues. The Nursing Home Administrator acknowledged that the usual housekeeper had quit, leading to a lapse in cleaning services. Another resident expressed concerns about not being able to use her closet due to a broken dresser, forcing her to keep her clothes and personal items in boxes. Despite reporting these issues to the staff, the Maintenance Director was unaware of the problem until the surveyor's inquiry. The Social Worker also acknowledged the need for residents to have proper storage for their belongings, indicating a lack of communication and follow-up on maintenance requests. Additionally, a resident's room was observed to be in disrepair, with peeling paint, loose trim, and a stained ceiling tile. The Maintenance Director was aware of these issues but had not yet addressed them, citing them as a priority. The Nursing Home Administrator admitted that the room did not provide a homelike environment, and plans for future renovations were mentioned, but the current state of the room remained inadequate for the resident's comfort and safety.
Deficiencies in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary services for residents who are unable to carry out activities of daily living (ADLs), resulting in deficiencies in nutrition, grooming, personal, and oral hygiene for four residents. Resident 48 did not receive her scheduled showers twice a week, as documented on multiple occasions. Despite her cognitive intactness, she expressed dissatisfaction with the infrequency of her showers, which were supposed to occur on Tuesdays and Thursdays. The Director of Nursing (DON) acknowledged that the resident should receive showers as scheduled and additional ones if needed. Resident 38, who has severe cognitive impairment due to parkinsonism and unspecified dementia, did not receive the recommended oral hygiene care. The resident's care plan required assistance with brushing and flossing twice daily, as per the dentist's recommendations. However, documentation showed that oral hygiene was only provided once a day on several dates. The DON confirmed that the care plan did not include the necessary flossing assistance, and a CNA reported a lack of flossing supplies in the facility. Resident 15, with severe cognitive impairment and a self-care deficit, did not receive daily oral care as required. The Point of Care (POC) history inaccurately documented the resident as independent or not applicable for oral care on numerous occasions. Interviews with the resident's Power of Attorney and CNAs revealed that the resident was fully dependent on staff for oral hygiene, and there was confusion about the documentation process. Additionally, Resident 16 had visibly long and dirty fingernails, indicating a lack of assistance with grooming. Staff acknowledged the oversight, citing being behind on tasks as a reason for neglecting nail care.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged wait times for assistance and unmet care needs. Multiple residents reported waiting over an hour for call lights to be answered, particularly during weekends when staffing levels were lower. This lack of timely response led to frustration and feelings of neglect among residents, with some resorting to extreme measures such as calling the police for help. The facility's policy on call light response was not adhered to, as evidenced by residents' accounts of staff turning off call lights without providing immediate assistance. Interviews with staff members revealed that the shortage of nursing staff impacted their ability to complete essential tasks, such as assisting residents with walking, toileting, and performing restorative exercises. Certified Nursing Assistants (CNAs) reported being responsible for caring for 12 to 13 residents each shift, exceeding the facility's stated average nurse aide-to-resident ratio of 1:10. This staffing inadequacy resulted in incomplete care, with tasks like showering, teeth brushing, and range of motion exercises often left undone, compromising the residents' quality of life. The Director of Nursing (DON) acknowledged the staffing challenges and the lack of documentation for call light audits. Despite management's efforts to assist on the floor, the facility's assessment tool for determining appropriate staffing levels was not effectively implemented. The discrepancy between the expected and actual call light response times further highlighted the staffing deficiencies, as residents continued to experience delays in receiving necessary care and assistance.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to document and resolve grievances for a resident, R23, who reported issues with Hoyer lift transfers and an interaction with a staff member. R23's care plan indicated the need for a Hoyer lift with a specific sling for toileting needs. However, the facility used a different Hoyer lift that was too short, causing R23's buttock to rub against the bed during transfers, resulting in pain. Despite staff, including CNAs and the DON, being aware of the issue, no grievance was documented or resolved. Additionally, R23 reported a grievance regarding a rude comment made by a CNA, which was documented in a letter intended for the DON. R23 was unsure if the letter was delivered, and the DON confirmed not receiving it. The facility's grievance policy requires grievances to be documented and resolved promptly, but this was not followed in R23's case. The facility's failure to document and resolve grievances violated its grievance policy, which mandates that grievances be recorded, investigated, and resolved within five days. The lack of documentation and resolution for R23's grievances highlights a deficiency in the facility's grievance handling process.
Failure to Provide Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure that a baseline care plan was reviewed with the resident or their representative and that a copy or summary of the care plan was provided within 48 hours of admission. This deficiency was identified for one resident, who was admitted with diagnoses including anoxic brain damage and a history of traumatic brain injury. The facility's policy requires that a baseline care plan be developed and shared within 48 hours of admission, but this was not done for the resident in question. Interviews with facility staff revealed inconsistencies in the process of initial care planning. The Minimum Data Set (MDS) coordinator indicated that the initial care plan is created through assessments in the electronic health record and discussed during the initial care conference, which is scheduled within 72 hours. However, the Licensed Practical Nurse (LPN) and Social Worker (SW) confirmed that the care plan is typically reviewed with the resident or representative at the care conference, not within the required 48-hour timeframe. The Director of Nursing (DON) was unable to confirm if the initial care plan was shared with the resident or representative within 48 hours, acknowledging the expectation that it should be.
Failure to Develop Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R54, who was reviewed for person-centered care plans. R54, who has a history of hemiplegia affecting the left side, malignant neoplasm of the brain, anxiety, and depression, expressed that staff did not handle her left arm in a way that prevented pain. Despite R54's moderate cognitive impairment, she communicated her discomfort and specific needs regarding the handling of her left arm, which were not documented in her care plan or the CNA Kardex. During an observation, a CNA was seen assisting R54 from a recliner to a bed and grabbed R54's left mid-forearm, causing R54 to express pain. The CNA admitted to habitually grabbing the arm despite R54's regular requests not to. The Director of Nursing acknowledged that the CNA should have stopped when R54 expressed pain and dizziness and should have involved a nurse for assessment. The DON also confirmed that R54's specific preferences should have been included in her care plan, which was not done.
Deficiencies in Resident Care Planning and Documentation
Penalty
Summary
The facility failed to ensure that residents or their representatives had the right to participate in the care planning process, as evidenced by deficiencies found in the cases of two residents. One resident, who was cognitively intact, reported not having quarterly care plan meetings to discuss her care. The facility's records confirmed that there was a lack of documentation for a quarterly care plan meeting between her admission and the most recent quarterly care conference. This indicates a failure to involve the resident in the care planning process as required by the facility's policy. In another case, a resident's care plan was not updated to reflect a change in her code status to Do Not Resuscitate (DNR), despite the presence of a signed DNR form and her admission to hospice care. The facility's comprehensive care plan incorrectly listed her as Full Code. The staff responsible for updating care plans acknowledged the oversight, indicating that the care plan should have been updated when the DNR form was signed. This failure to update the care plan demonstrates a lack of adherence to the facility's policy of revising care plans to reflect significant changes in a resident's status.
Delayed Transcription of Medical Orders
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident who had received medical orders that were not transcribed for two days. The resident had a healed wound on the right heel and received new orders from the physician, which included nutritional supplements, dressing changes, surgery for debridement, an antibiotic, and a lipid profile. These orders were received via fax but were not processed until two days later, resulting in a delay in treatment. Interviews with facility staff, including an LPN, the ADON/IP, and the DON, confirmed that the orders should have been transcribed on the day they were received. The delay was acknowledged by the facility, and it was noted that the resident's primary care provider and family were made aware of the situation. Despite the delay, the resident did not experience any adverse effects from the lapse in timely order processing.
Inconsistent Wound Care for Residents with Pressure Injuries
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice. This deficiency was identified for three residents, who did not have their wound treatments completed as ordered. The facility's policy required wound treatments to be provided according to physician orders and documented in the Treatment Administration Record (TAR) or electronic health record. However, the survey revealed that treatments were not consistently administered or documented for these residents. One resident, with multiple stage 4 pressure ulcers and a history of paraplegia, chronic pain, schizophrenia, and bipolar disorder, frequently left the facility without receiving prescribed wound care. The resident's TAR showed numerous instances where treatments were not completed, and interviews with staff indicated that wound care was performed based on the resident's schedule rather than consistently at the same time each day. Another resident, with a history of hemiplegia, diabetes, and peripheral vascular disease, also had missed wound care treatments documented in the TAR. Despite physician orders, treatments were not completed on several occasions, and staff interviews confirmed that a blank in the TAR indicated a missed treatment. A third resident, admitted with paraplegia, diabetes, lung cancer, and morbid obesity, also experienced missed wound care treatments. The TAR indicated that treatments were not documented as completed on multiple occasions. Interviews with the Director of Nursing confirmed that a blank in the TAR meant the treatment was not done, and wound care was expected to be completed as ordered. These failures to provide consistent wound care as per physician orders contributed to the deficiency identified by the surveyors.
Deficiencies in Resident Safety and Policy Adherence
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents. One resident, who was admitted with conditions including critical illness myopathy and acute respiratory failure, was found to be smoking without a proper assessment or care plan in place. Despite being cognitively intact, the resident was not listed as a smoker in the facility's records, and staff were aware of her smoking habits but did not complete the necessary evaluations or care plans. Another resident's electric wheelchair was observed charging in his room, contrary to the facility's policy that requires such devices to be charged in designated areas. Staff, including a CNA, ADON/IP, and DON, were unaware of the correct charging location, indicating a lack of communication and adherence to the facility's policy on power mobility devices. A third resident, who was cognitively intact and had diagnoses including parkinsonism and respiratory failure, used an electric scooter in the community without a prior safety assessment. The assessment was only completed after the resident had already used the scooter, which was against the facility's policy that requires an evaluation before the use of electric devices to ensure safety.
Medication Administration Error with Lidocaine Patch
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, identified as R32, by not ensuring the proper administration and removal of a lidocaine patch. On September 10, 2024, it was observed that R32 had a lidocaine patch still on her arm that should have been removed the previous night. The facility's policy on medication administration requires medications to be administered as prescribed and removed according to schedule. However, during a medication administration session, an LPN discovered that the patch on R32's arm was not dated or initialed, indicating a lapse in following the facility's procedures. Further investigation revealed that the facility was out of stock of the prescribed 5% lidocaine patch, and a switch to a 4% patch was ordered by a Nurse Practitioner. However, there was no documentation that the Nurse Practitioner was informed about the patch being left on overnight. The Director of Nursing acknowledged the incident as a medication error, noting that the nurse should have contacted the doctor regarding the error to determine the appropriate course of action.
Medication Errors Exceeding Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 10.71%, exceeding the acceptable threshold of 5%. This was determined during a medication pass task involving four supplemental residents, where three errors were identified out of 28 opportunities. Two residents, R31 and R32, were directly affected by these errors. The errors were observed by a surveyor and involved incorrect dosing and medication administration. For resident R31, the error involved the administration of Sevelamer, a phosphate binder used to prevent low levels of calcium. The resident's medication administration record (MAR) indicated a prescription of two 800 mg tablets to be taken three times a day. However, RN H only prepared and dispensed one tablet. Upon being questioned by the surveyor, RN H acknowledged the mistake and corrected it by providing the second tablet before administering the medication to R31. Resident R32 experienced two medication errors. LPN I initially prepared and almost administered a medication intended for another resident, R463, before being corrected by the surveyor. Additionally, R32's prescribed 5% lidocaine patch was not applied as it was unavailable, and a 4% patch was used instead without proper documentation or notification to the nurse practitioner. The surveyor also noted that R32 had a lidocaine patch on her arm without a date or initials, indicating it had not been removed the previous night as required.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards, as observed during a survey. In the medication room, five bottles of liquid Tylenol were found with expiration dates of July 2024, indicating they were expired and should not have been stored there. Additionally, an open vial of Lantus insulin for a resident was found in the medication room refrigerator without an open date, making it unclear how long it had been in use. The facility's policy requires medications to be labeled with an open date to ensure they are used within their effective period. On a medication cart, three bottles of artificial tears were found improperly labeled, with one bottle missing both the first and last name of the resident and an open date, while the other two bottles only had first names and no open dates. This lack of proper labeling could lead to confusion about which resident the medications belonged to, especially if residents shared the same first name. Interviews with nursing staff confirmed that the medications should have been labeled with full resident names and open dates to ensure proper administration and compliance with the facility's medication administration guidelines.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that all residents received food at a palatable temperature, as evidenced by observations, interviews, and record reviews. Resident R467, who has diagnoses including Type 2 Diabetes Mellitus, Essential Hypertension, and atherosclerotic heart disease, reported to the surveyor that the food served was cold. Similarly, Resident R41, who has a mild cognitive impairment as indicated by a BIMS score of 12, expressed concerns during a resident council meeting that hot food was sometimes served lukewarm and had been sent back to the kitchen for being cold. Additionally, a test tray was observed by the surveyor, with the meat and gravy measuring 111°F, noodles at 109°F, and mixed vegetables at 115°F, all of which were below the proper serving temperatures. The noodles were noted to be mushy and not palatable. The Nutrition Services Director acknowledged the issue, attributing it to staff leaving the warming box open while placing trays, causing the heat to escape. The facility's policy requires food temperatures to be recorded daily to ensure they meet food code standards, which was not adhered to in this instance.
Deficiency in Food Storage and Labeling in Medication Room Refrigerator
Penalty
Summary
The facility failed to ensure that food stored in the medication room refrigerator was labeled and managed according to professional standards. During an inspection, surveyors observed that three cartons of thickened liquids and two half gallons of chocolate milk were opened and expired. The facility's policy on 'Food Safety Requirements' mandates that all food items be inspected for safe transport and quality upon delivery, and that refrigerated items be labeled, dated, and monitored to ensure they are used by their use-by date or frozen. However, the surveyor found that the medication room refrigerator contained items that were not properly labeled with open dates, and some items were past their recommended consumption period. Interviews with facility staff, including an LPN and the DON, revealed a lack of clarity and adherence to the policy. The LPN indicated that supplements and food items should be discarded if expired, but was unable to identify the owner of the chocolate milk. The DON confirmed that items in the medication refrigerator should have open dates and be discarded if expired, and mentioned that the night shift is responsible for cleaning out the refrigerator. Despite these procedures, the expired items were not removed, indicating a lapse in the facility's food safety practices.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 263 citations issued within 25 miles in the last 12 months — including the 8 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 Beloit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Beloit | 1.1 mi | ★★★★★ | 16 | 0 |
| Fair Oaks Rehab & Healthcare | 5 mi | ★★★★★ | 26 | 1 |
| Alden Meadow Park Hcc | 7.4 mi | ★★★★★ | 11 | 0 |
| Cedar Crest Health Center | 7.8 mi | ★★★★★ | 4 | 0 |
| Oak Park Place Of Janesville | 8.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.