Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Clairidge House during CMS and state inspections, most recent first.
The facility failed to provide timely and comprehensive pressure injury care for multiple residents. A resident with high pressure injury risk developed a stage 3 elbow wound that was not fully assessed at discovery and was not reflected in the care plan when the wound changed. Another resident had facility-acquired thigh pressure injuries linked to an improperly sized brief, but one wound was not assessed or treated until the surveyor intervened, and an RN applied the wrong treatment to the other wound. Additional residents had delayed reassessment after readmission, missed treatments, and lack of heel offloading.
Failure to notify the physician of a significant weight loss for a resident with Alzheimer’s disease, vascular dementia, DM2, CKD, and other chronic conditions. The resident’s weight dropped from 141 lbs to 118 lbs, and the RD documented the loss and discussed it with an RN, but no physician consult was documented and the re-weigh was never obtained. The RD did not know who notifies the physician, and the care plan had not been updated.
Incomplete Employee Background Screening: The facility did not ensure employee abuse screening was completed before staff began working. Record review showed multiple employees had missing, unsigned, or late background checks, including out-of-state screening and DOJ/IBIS checks completed after hire. The NHA stated staffing changes contributed to screenings not being completed.
Smoking Hazards and Incomplete Fall Investigations: A resident was observed vaping in bed and two other residents had smoking materials in their rooms despite care plans restricting possession and requiring nurse control of those items; quarterly smoking assessments were also missing. Another resident with dementia and repeated falls had fall investigations that lacked root cause analysis and staff statements, while surveyors repeatedly found the call light on the floor and out of reach despite care plan interventions.
Failure to Document CAA Summaries for Triggered MDS Care Areas: The facility did not document required CAA summary information for triggered MDS care areas for two residents. One resident was non-verbal, dependent on staff for all ADLs, and had a stage 1 pressure injury, but the Pressure Injury CAA summary did not include the analysis or rationale for care planning. Another resident, admitted with multiple diagnoses including PVD, Type 1 DM, bipolar disorder, and an indwelling urinary catheter, had multiple CAAs triggered on the admission MDS, but no summary information or rationale was documented for the triggered areas.
A resident with anxiety, bipolar disorder, and severe depression with psychotic features had a psychiatric hospitalization for worsening symptoms and suicidal ideation, then returned with new psychotropic medication orders. The facility completed PASARR only on admission and did not complete a new PASARR after the resident’s significant change in mental condition and medication changes, despite ongoing depression, suicidal thoughts, and psychotic symptoms.
Failure to Address Significant Decline in ADLs: A resident with dementia and multiple chronic conditions had a marked decline from being ambulatory and needing partial/max assistance with some ADLs to being chair fast, dependent for transfers and mobility, and requiring more help with dressing, toileting, and bathing. The care plan and CAAs did not include comprehensive, person-centered interventions, and staff interviews confirmed the decline while also stating that therapy referral was not attempted despite the change in function.
A resident with dementia, dysphagia-related diet changes, and diabetes had a documented 16.31% weight loss, but the facility did not obtain a requested reweigh or ensure meal intake was monitored as care planned. The RD noted the significant weight loss and discussed it with an RN, yet the reweigh was not completed, intake documentation was missing for multiple meals, and the Nurse Manager was unaware of the need for the reweigh.
A resident with alcohol abuse and major depressive disorder continued drinking despite a care plan noting the issue. The resident had two falls tied to intoxication, but the facility did not add meaningful interventions beyond telling the resident not to drink, and no psychiatric consult was found in the record even though one was ordered. The SSD said AA was offered once, but no other supports were implemented.
A resident with Alzheimer’s disease and vascular dementia with behavioral disturbance did not receive person-centered dementia care or meaningful activity support. The resident’s care plan listed preferences such as music, cards, singing, Mass, and pet visits, but surveyors repeatedly observed the resident alone in the room tapping or banging objects on a table with no stimulation provided, and the resident was not seen participating in activities. Staff stated the facility had no dementia program, 1:1 visits were limited, and there had been no comprehensive assessment or individualized interventions for the resident’s behaviors.
A resident with major depression, anxiety, and a documented history of SI and psychiatric commitment was readmitted without a suicidal care plan or person-centered suicide prevention interventions. Psychiatric notes later documented ongoing SI, including thoughts of self-harm and a plan to overdose on pills, yet survey review found no monitoring of SI or medication hoarding in the MAR, TAR, orders, care plan, or CNA care card. SSD-H said she was unaware of the resident’s SI history and only handled discharge planning, while the DON acknowledged the resident’s SI history and that no personalized SI interventions were in place.
A resident with a history of vertebral fracture, chronic pain, and depression returned from an ER visit with instructions for scheduled Tylenol and PRN ibuprofen for hip pain, but the new pain regimen was not promptly reflected in the MAR or reviewed with the MD. The resident also received repeated PRN tramadol doses without documented pain ratings, pain descriptions, locations, or follow-up effectiveness assessments, despite the care plan calling for monitoring and documentation of pain control.
A resident receiving hospice services was given Macrobid for a reported burning sensation in the vaginal area, but the record lacked clinical indications or physician documentation to support antibiotic use. RN documented the hospice order, and the MAR showed the antibiotic was administered BID for 7 days for a UTI. The DON later stated she was not aware hospice had ordered the antibiotic and that it did not meet the clinical definitions of use.
Failure to Use EBP PPE During Resident Care: A resident with an unhealed stage 3 pressure injury, frequent urinary incontinence, and bowel incontinence had no EBP sign or PPE available at the room. CNA staff provided hygiene, incontinence care, dressing, and transfer without EBP PPE, and later CNA staff again assisted with care while only wearing gloves. RN staff also performed wound treatment, and the wound nurse confirmed the resident should have been on EBP due to the pressure injuries.
The facility failed to offer and document influenza immunizations for two residents reviewed for vaccines. One resident had acute respiratory failure with hypoxia and asthma, and another had dyspnea, emphysema, and chronic respiratory failure with hypoxia. The EMR contained no documentation that either resident received the flu vaccine, received education on benefits and side effects, or refused the vaccine; the DON stated one resident was not offered the vaccine because admission occurred after the flu clinic, despite the facility policy requiring vaccination on admission for residents admitted during the winter months.
Failure to Offer and Document COVID-19 Vaccination for a Resident: A resident admitted with dyspnea, emphysema, and chronic respiratory failure with hypoxia was not offered the COVID-19 vaccine, and the EMR had no documentation of vaccine education, receipt, contraindication, or refusal. The DON stated the resident was not offered the vaccine because admission occurred after the facility's vaccine clinic, despite policy requiring education and offering the vaccine when available.
The facility did not report allegations of misappropriation of funds and neglect to the State Survey Agency as required. A resident with severely impaired decision-making skills reported missing money after a cash withdrawal, but the NHA said the allegation was not reported because the resident was confused and the guardian was unaware of any issue. In a separate case, a resident with intact cognition had a grievance involving a fall and alleged refusal to send the resident to the hospital; the NHA reviewed records, questioned the allegation’s validity, and did not report it to the State Agency.
The facility did not thoroughly investigate allegations of missing resident funds and neglect involving two residents. One resident with severely impaired decision-making reported missing money after withdrawing cash, but the NHA did not fully investigate the allegation and the file contained only limited statements. Another resident with intact cognition had a neglect-related grievance that was also not thoroughly investigated, despite the facility policy requiring all alleged violations to be fully investigated.
The facility failed to designate a Director of Food and Nutrition Services, leaving the dietary department without proper supervision. Cook1, who was previously the interim Director, did not meet the required qualifications, and recruitment efforts for a Certified Dietary Manager were unsuccessful. The Registered Dietitian provided limited clinical services and did not inspect the kitchen for sanitation issues, increasing the risk of foodborne illness for all 41 residents.
The facility failed to maintain the required sanitizer level in the low temperature dishwasher, as observed when a dietary aid tested the chlorine level and found it to be zero ppm. Despite this, the aid continued to wash dishes, violating the facility's policy that mandates a chlorine level between 50 ppm and 100 ppm. The deficiency had the potential to cause foodborne illness or infections among all 41 residents.
The facility failed to ensure a clean and homelike environment, with observations of unsanitary conditions in resident bathrooms, including soiled call cords, a strong urine odor, and a loose toilet seat. These issues affected several residents, some of whom were cognitively impaired or required assistance with toileting. The facility's housekeeping policies were not followed, contributing to these deficiencies.
A facility failed to document a resident's feeding tube in the MDS assessments, despite the resident having a gastrostomy status since admission. The MDS Coordinator and DON confirmed the oversight, acknowledging that the feeding tube should have been coded in the assessments, as per the RAI manual.
A facility failed to obtain a physician's order for a resident with an indwelling urinary catheter, diagnosed with neurogenic bladder. The care plan noted the presence of a Foley catheter, but the physician's orders lacked details such as catheter type, size, and maintenance instructions. Interviews with staff confirmed the absence of necessary orders, violating the facility's catheter management policy.
A facility failed to ensure a resident with a gastrostomy tube had a physician's order for tube care. Despite the resident's medical history of severe protein malnutrition and dysphagia, the MAR indicated daily flushing of the tube without a documented physician's order. Staff interviews confirmed the absence of the necessary order, contrary to facility policy.
A resident with diabetes did not receive his medication as prescribed, as a pill was left in a cup on his bedside table. The resident confirmed he was not awakened to take his medication, and no assessment for self-administration was conducted. The DON stated that medication should not be left in a resident's room and must be administered by a nurse.
A facility failed to secure controlled substances under double lock and ensure proper documentation, leading to potential drug diversion. An LPN did not sign the controlled substances she administered, assuming the previous shift nurse had forgotten. The DON was not informed of the missing signatures, and the Master Control Substance record had multiple omissions. Additionally, an RN left a refrigerator containing Ativan unlocked, violating the facility's policy.
A facility failed to prepare and educate staff for the care of a resident with a chemotherapy infusion pump. The resident, with a history of hepatitis C, HIV, and rectal cancer, returned from a clinic with the pump, but nursing notes lacked documentation of its presence. Staff interviews revealed they were not trained on managing the pump or chemotherapy drugs, and the facility assessment did not cover such care. The physician's order also lacked instructions for handling hazardous material, posing potential risks to residents and staff.
Incomplete Pressure Injury Assessment and Treatment
Penalty
Summary
The facility did not ensure residents with pressure injuries received comprehensive assessments, timely interventions, and treatment to prevent worsening or new wounds. R3 was admitted with stroke, was non-verbal, tube fed, totally dependent for positioning, and at high risk for pressure injury with a Braden score of 11. R3 developed a facility-acquired stage 3 pressure injury to the right elbow that was first noted in the 24-hour report as an old wound reopened, but there was no comprehensive wound assessment or documented treatment plan at discovery. The wound was not comprehensively assessed until several days later, and the record also showed gaps in reassessment after readmission from the hospital, with no comprehensive assessment of the right elbow until after return to the facility. R3’s wound record showed repeated assessments of the right elbow over time, but the initial discovery and early management were incomplete. The wound nurse stated the floor nurse should have notified wound staff when the wound was found, and the surveyor noted the elbow protectors were too tight and that a positioning wedge may have contributed to the wound. After R3 returned from the hospital, the right elbow was again not comprehensively assessed until later, and the plan of care was not updated when the wound deteriorated or when treatment changed. The record also showed periods where the wound was assessed weekly by the NP, but the care plan did not reflect corresponding changes in interventions despite changes in wound status. R9 had facility-acquired pressure injuries to the left posterior thigh and left medial thigh. R9 was cognitively intact, dependent for toileting and lower body dressing, and frequently incontinent of urine and always incontinent of bowels. Surveyor observed that R9’s brief fit snugly, and R9 stated the brief was sometimes too tight and staff did not readjust it. The facility identified the root cause of the wounds as incorrect brief sizing, but the left medial thigh stage 2 device-related pressure injury was not assessed and treatment was not initiated until the surveyor questioned it. On another occasion, RN-T provided incorrect wound care to the left posterior thigh stage 3 pressure injury by applying zinc oxide instead of the ordered treatment, and the wound was left uncovered when the surveyor observed it. R1 was admitted with multiple diagnoses including diabetes, peripheral vascular disease, and an indwelling urinary catheter, and had a deep tissue injury to the left heel on admission to the hospital. After R1 returned to the facility, no skin assessment was documented, and the left heel pressure injury was not comprehensively assessed until about a week later. R16 had a stage 3 pressure wound on the right heel, was observed without heels floated during the survey, and the Treatment Administration Record documented missing treatments. The record also noted a history of MASD and a prior pressure wound to the left heel.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility did not ensure the physician was consulted regarding a possible change in condition for one sampled resident, R20, after a significant weight loss was identified. R20 was admitted with diagnoses including Alzheimer’s disease, vascular dementia with behavioral disturbance, type 2 diabetes mellitus, hypothyroidism, hyperlipidemia, chronic kidney disease, and hypertensive heart disease. The resident’s MDS assessed impaired memory, severely impaired daily decision-making, no range of motion impairment, set-up assistance for eating, food held in mouth, no current weight loss, and a mechanically altered diet. Monthly weights showed R20 weighed 141 pounds on 12/17/25 and 118 pounds on 2/19/26, a 16.31% loss. The facility’s Physician Notification-Consultation Parameters listed unexplained weight loss of 5% or more within 30 days or 10% or more within 6 months as a condition requiring notification/consultation. On 2/25/26, the RD documented the significant weight loss and discussed it with an RN, who was to obtain a re-weight to assess accuracy because the weight had previously been stable. However, survey review of the EMR and paper chart found no documentation that R20’s physician had been consulted about the significant weight loss, and the re-weight was never obtained. R20’s nutrition care plan had not been updated since 12/9/25. The RD stated that if a resident had significant weight loss, high protein and high calorie would be added to daily meals, but did not know who notifies a physician of significant weight loss. The DON stated weight loss, change in condition, falls, and abnormal labs were reasons to notify a physician, and the CNO later stated the facility believed the 2/19/26 weight was wrong after a re-weigh showed 140 pounds, but there was still no physician notification documented.
Incomplete Employee Background Screening
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited because the facility did not ensure employees were screened for abuse before they began working. Record review showed that 4 of 8 staff reviewed had incomplete or late background screening documentation. CNA-M was hired after working out of state, but the other-state background check was not completed by the hire date. CNA-O was also hired after working out of state, and the other-state background screening was not completed by the hire date. The Dietary Manager, N, had a Background Information Disclosure that was not signed or dated, and the DOJ and IBIS were not completed until after the hire date. CNA-P’s DOJ and IBIS were also completed after the hire date. The facility policy titled Resident Safe Abuse Policy, dated 3/24, required all employees to have criminal background checks, including any required future checks in accordance with applicable state and federal laws. During interview, the NHA stated they had been completing employee background screenings, but there had been changes in staff and the screenings were not being completed, and they acknowledged that out-of-state checks were not run for CNA-M and CNA-O.
Smoking Hazards and Incomplete Fall Investigations
Penalty
Summary
The facility did not ensure the environment remained free of accident hazards related to smoking materials for residents who smoked. One resident with diagnoses including nicotine dependence, bipolar disorder, insomnia, peripheral vascular disease, and diabetes was observed lying in bed and actively vaping under the covers in the resident room. The resident stated that staff could not take the vaping device away if they did not see it being used. Facility staff interviewed after the observation stated residents were not supposed to smoke in rooms, but also stated they had to catch the resident actively smoking before they could confiscate smoking materials. The resident’s record showed only an admission smoking assessment and no quarterly smoking assessments were documented. A second resident with schizoaffective disorder, nicotine dependence, and a movement disorder was found with smoking materials in the room despite care plan directions that the resident may not possess smoking materials and that all smoking materials were to be kept with the nurse for distribution as requested. Surveyors observed a lighter in the resident’s pocket, cigarettes in the pocket, and cigarettes and a lighter in the room on multiple occasions. The resident told surveyors the facility had caught the resident smoking in the room and that smoking materials had to be given to the nurse. Facility staff gave inconsistent responses about whether all smoking materials were being removed, and the resident’s quarterly smoking assessments were not completed on a quarterly basis. A third resident, who had a BIMS score of 11 and was documented as a long-term smoker, also did not have smoking assessments completed on a quarterly basis. The most recent smoking assessment in the record was dated months earlier, despite the resident continuing to smoke. Facility leadership stated smoking assessments were expected quarterly and updated as needed, but the record did not show that this occurred. In addition, the facility observed that another resident with dementia and a history of falls had repeated falls that were not thoroughly investigated. The resident had multiple falls, including unwitnessed falls and a witnessed fall, but the fall investigations did not document a root cause analysis or staff statements. Surveyors also repeatedly observed the resident’s call light on the floor and out of reach, and the resident was observed sitting or lying in positions where the call light was not accessible. The resident’s care plan included interventions such as call light in reach and being assisted to bed after lunch, but surveyors observed the call light out of reach and the resident not consistently in the planned resting location.
Failure to Document CAA Summaries for Triggered MDS Care Areas
Penalty
Summary
The facility did not document a summary of information for care areas triggered by the completion of the MDS for 2 of 5 sampled residents, including R3 and R1. The report states that the facility failed to complete the required CAA summary information for triggered assessment areas, including the analysis of the information and the rationale for whether to proceed with care planning. The facility policy and procedure for Resident Assessment Instrument and Person-Centered Care Planning states that the CAA process is used by the IDT to interpret MDS information and determine whether to proceed to the care plan. R3 was admitted to the facility and was non-verbal and dependent on staff for all ADLs. R3's admission MDS completed on 7/7/25 triggered a Pressure Injury CAA, and the CAA checked that R3 was at risk for pressure injury, totally dependent on staff, non-verbal, and had a stage 1 pressure injury. The CAA summary only documented that R3 triggered the CAA due to requiring full cares related to a pressure ulcer present on admission, but did not document the analysis or rationale for care planning. R1 was admitted with diagnoses including idiopathic aseptic necrosis of the left toe, pneumonia, peripheral vascular disease, nicotine dependence, Type 1 diabetes mellitus, bipolar disorder, insomnia, and neuromuscular dysfunction of the bladder requiring an indwelling urinary catheter. R1's admission MDS triggered CAAs for ADLs, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer, psychotropic drug use, pain, and return to community referral, but no summary information or rationale for those triggered areas was documented.
Failure to Complete New PASARR After Significant Mental Status Change
Penalty
Summary
The facility did not ensure it notified the state mental health authority promptly for a resident review after a significant change in mental condition for one resident reviewed for PASARR. The resident had diagnoses including generalized anxiety disorder, bipolar disorder, and current episode of depression, severe, with psychotic features, and the quarterly MDS showed a BIMS score of 14 with no behavior concerns and use of antipsychotic, antianxiety, and antidepressant medications. After readmission in June 2025 following a psychiatric hospitalization for high anxiety, panic attacks, decreased appetite, and significant depression with suicidal ideation, the resident returned with medication changes including monthly Invega injections, Depakote three times daily, and trazodone at bedtime. The record also documented ongoing psychiatric follow-up with worsening depression, suicidal thoughts, and concern about saving medications to overdose, and a later psychiatric evaluation described severe depressive symptoms with psychotic features, chronic suicidal thoughts, delusional thoughts, and visual and auditory hallucinations. During interview, the Social Services Designee stated PASARRs were done only on admission and that only one PASARR had been completed for the resident, with no new PASARR completed after readmission and medication changes.
Failure to Address Significant Decline in ADLs
Penalty
Summary
The facility did not ensure that one resident with a significant decline in activities of daily living (ADLs) received appropriate treatment to maintain or improve functional ability. The resident had diagnoses including Alzheimer’s disease, vascular dementia with behavioral disturbance, type 2 diabetes mellitus, hypothyroidism, hyperlipidemia, chronic kidney disease, and hypertensive heart disease, and had an activated HCPOA. The resident’s September MDS showed memory impairment, severely impaired daily decision-making, no range of motion impairment, independence in mobility and transfers, and assistance needs for eating, toileting hygiene, bathing, and dressing. By the December significant change MDS, the resident had worsened ADL status, including substantial/maximum assistance for mobility and transfers, dependence for toileting hygiene, bathing, and dressing, pocketing food, a mechanically altered/pureed diet, and walking not attempted due to medical condition. The resident’s annual CAA for nutrition was blank, and the annual CAAs for falls, ADL, and cognition did not document a comprehensive summary of triggered symptoms and interventions. The comprehensive care plan noted increased need for ADL assistance, but the only updated interventions were general measures such as assessing functional level, administering medications, observing for side effects, reorienting as able, using a calm approach, and offering simple instructions. The care plan did not document person-centered interventions to address the resident’s increased need for ADL assistance. Staff documentation also noted that the resident had become chair fast, had decreased dressing, transfer, and bed mobility ability, and tired easily. Surveyor interviews confirmed the decline and the lack of therapy involvement. A CNA stated the resident needed increased assistance and was incontinent of bowel and bladder. An RN stated the resident’s ADL assistance decreased around medication changes and acknowledged the resident’s ADL status had changed significantly. The SSD stated the resident was not doing much, had changed, and it had become difficult for the resident to stand. The NM confirmed the resident was weaker and said therapy referral was not discussed or attempted. The DON stated therapy was probably discussed but never attempted and did not believe the resident could follow directions for therapy. The facility later provided a rehabilitation referral dated after the survey began, documenting prior ambulation and increased assistance needs, along with a therapy payer verification form.
Failure to Monitor Intake and Reweigh Resident After Significant Weight Loss
Penalty
Summary
The facility did not ensure that a resident with documented weight loss maintained acceptable nutritional status. R20 was admitted with Alzheimer’s disease, vascular dementia with behavioral disturbance, and type 2 diabetes mellitus. The resident’s significant change MDS indicated severe cognitive impairment, required set-up for eating, held food in the mouth, and was on a mechanically altered diet. The care plan addressed potential weight fluctuation and altered nutrition, including monitoring food intake, offering snacks, assisting with eating, monitoring fluid intake, and ensuring the ordered diet was followed. R20’s record showed the diet was changed from regular to pureed after the resident was observed pocketing food, holding food in the mouth, and having delayed swallowing. Weight records showed R20 weighed 141 pounds on 12/17/25 and 118 pounds on 2/6/26 and 2/19/26, a 16.31% loss. The surveyor also reviewed meal intake records and found 15 meal intakes in December and 46 meal intakes in January with no documentation. The facility’s Weight Management policy required the licensed nurse to determine whether an additional reweight was needed and to notify the RD of significant or severe weight changes, and the Persons at Risk Program required review of weight trends, intake documentation, RD documentation, and care plan updates for residents with significant weight loss. On 2/25/26, the RD documented a significant weight loss and discussed the concern with RN-D, who was to obtain a reweight to assess accuracy, but the reweight was not obtained. During interview, the RD stated they had asked for a reweight and would assess intake, while the Nurse Manager did not know about the need for a reweight. The surveyor also found staff were not monitoring R20’s intake at meals as care planned, and the facility had not completed follow-up person-centered interventions related to the documented weight loss.
Failure to Provide Behavioral Health Services for Resident with Alcohol Abuse
Penalty
Summary
The facility did not provide necessary behavioral health care and services for a resident with a history of alcohol abuse and major depressive disorder. The resident’s quarterly MDS documented a BIMS score of 11, indicating moderately impaired decision-making skills, and the care plan noted the resident continued to drink alcohol. The care plan, initiated on 4/7/25, included interventions to monitor and report suspected intoxication, re-educate the resident on the risks of continued alcohol abuse, and provide for safety and wellbeing, but survey review found the care plan had not been updated with additional interventions since that date. The resident had two falls that the facility determined were related to drinking alcoholic beverages and intoxication, first on 12/6/25 and again on 12/13/25. After the first fall, the only documented post-fall intervention was for the resident not to drink, and surveyors found no supports or interventions were implemented to address the resident’s continued alcohol use. The medical record also showed an order dated 2/20/26 for psychiatric services to evaluate and consult regarding the resident, but surveyors could not locate any psychiatric evaluation in the electronic record or paper chart. During interview, the SSD stated they only completed discharge care plans, had no training beyond leadership training, recalled offering AA once without documenting it, and confirmed no other interventions were implemented.
Failure to Provide Person-Centered Dementia Care and Activities
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with dementia and behavioral symptoms so the resident could attain or maintain the highest practicable physical, mental, and psychosocial well-being. The resident had diagnoses including Alzheimer’s disease and vascular dementia with behavioral disturbance, and the MDS indicated short- and long-term memory impairment and severely impaired daily decision-making skills. The resident’s care plan identified dementia-related concerns including perpetual motion, wandering, anxiety, and disruptive behaviors such as tapping on surfaces and digging in a brief, and also documented preferences for music, cards, singing, Christmas music, Mass, and pet visits. During the survey, the resident was repeatedly observed sitting alone in the room with an overbed table in front, tapping or banging objects on the table, with no music or television on and no items provided for stimulation. The resident was also observed sleeping in bed at multiple times, and the surveyor noted the resident was not observed out of the room during the survey and was not observed participating in any activities. On one observation, the resident’s call light was on the floor and not within reach. The facility’s activity staff stated the resident sometimes attended online church and movies but needed 1:1 monitoring, and that only one staff member was available, making it hard to bring the resident to activities. The Activity Director also stated 1:1 visits were provided only once a week, usually to read a devotion, and confirmed there was no dementia activity programming for residents with dementia or dementia-like symptoms. The Social Services Designee stated the facility did not have a dementia program and acknowledged dementia care was important. The resident’s MARs documented no targeted behaviors, and the report states there had been no comprehensive assessment with individualized interventions for the resident’s behaviors or person-centered dementia care interventions.
Failure to Provide Social Services and Suicide Prevention Care Planning
Penalty
Summary
The facility did not ensure that 1 resident received medically related social services to achieve the highest practicable mental and psychosocial well-being. The resident had diagnoses including major depressive disorder and generalized anxiety disorder, and the record showed a history of suicidal ideation, mania, and psychosis with a court-ordered psychiatric commitment for 6 months after a finding of dangerousness due to substantial probability of physical harm to self. Despite this history, the resident was readmitted to the facility without a suicidal care plan and without person-centered interventions specific to suicide prevention in the care plan. The resident’s chart included multiple psychiatric notes documenting ongoing suicidal ideation and depression. One note stated the resident thought about harming self and wished to do so, and another documented significant depression with a stated plan to save up medications to overdose. Later psychiatric documentation continued to note suicidal ideation, bad depression, and the need for close safety monitoring at the facility, including supervised medication administration and observed swallowing. Survey review found no documented monitoring of suicidal ideation or medication hoarding in the MAR, TAR, orders, care plan, or CNA care card. Social Service Designee-H stated that the admission nurse handled initial care planning for behaviors and psychiatric services, that the psych NP sent follow-up visit information for scanning, and that SSD-H only worked on discharge planning. SSD-H stated being unaware of the resident’s suicidal history and said there would be a care plan and social services involvement if such history existed. The DON stated SSD-H oversaw social services related behaviors, psych, and care planning, acknowledged the resident had a history of suicidal ideation, and stated there were no personalized interventions in the care plan relating to suicidal ideation or prevention and no monitoring of suicidal ideation or medication administration observations.
Incomplete Pain Assessment and Medication Follow-Through
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of a resident receiving pain medications. The resident was admitted with diagnoses including a fracture of the fourth lumbar vertebra, chronic anal fissure, and major depressive disorder, and had a BIMS score of 14, indicating cognitive intactness for daily decision making. The resident’s care plan included interventions for pain management, including assessing symptoms, administering pain meds, monitoring effectiveness and side effects, documenting pain level, and notifying the MD as needed. After an ER visit for left hip pain, the resident returned to the facility with an After Visit Summary stating to take Tylenol 650 mg three times per day with or without ibuprofen 600 mg twice a day as needed for pain. The record did not show that this recommendation was reviewed with the resident’s physician or that medication orders were adjusted at that time to implement the recommendation. The resident’s physician orders continued to include PRN tramadol, and the recommended Tylenol dose from the ER visit was not added to the medication orders until several months later. The resident received multiple PRN doses of tramadol for pain management, but the facility’s pain documentation frequently lacked a pain rating before administration, a description or location of pain, and documentation of medication effectiveness afterward. Survey review identified numerous incomplete pain assessments across November, December, January, and February, including one entry noting pain was unchanged with no indication that anything further was done. The resident later stated that pain was not currently present and had been managed at the facility recently.
Unnecessary Antibiotic Use Without Supporting Clinical Documentation
Penalty
Summary
Ensure each resident’s drug regimen was free from unnecessary drugs was not met when R5 received the antibiotic Macrobid without adequate indications for use. R5 was admitted to the facility and was receiving hospice services. On 2/11/2026, RN-D documented that R5 complained of a burning sensation in the vaginal area, called the hospice nurse, and received an order to start Macrobid 100 mg PO BID for 7 days; the order was faxed to the primary provider and pharmacy, and R5 was placed on alert charting for 7 days. R5’s February 2026 MAR shows Macrobid 100 mg was administered BID from 2/12/26 through 2/17/26 for a UTI. The medical record did not contain documentation of clinical indications for the antibiotic or physician documentation to support its administration. During interview, the DON, who was also the facility Infection Preventionist, stated she was not aware hospice had ordered the antibiotic and said the medication did not meet the clinical definitions of use, with no further clinical information available regarding a UTI or antibiotic use.
Failure to Use EBP PPE During Resident Care
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for a resident with Enhanced Barrier Precautions (EBP) needs. The resident had diagnoses including acute kidney failure, acquired absence of the right foot, and urinary retention, and the MDS documented cognitive intactness, lower extremity impairment, dependence for toileting and lower body dressing, frequent urinary incontinence, always incontinent of bowels, and an unhealed stage 3 pressure injury. The facility policy stated that EBP are used in addition to Standard Precautions for residents with wounds or indwelling medical devices and require gown and glove use during high-contact resident care activities, including hygiene, changing briefs, transferring, and wound care. On observation, the resident had no EBP sign on the door and no PPE available in or near the room. CNA staff entered the room without EBP PPE and assisted the resident with undressing, a partial bed bath, incontinence care, dressing, and transfer with a Hoyer lift. During this care, the surveyor observed two adhesive dressings on the resident’s buttocks, scant red matter in the brief near the left thigh, and a large open wound on the left medial thigh. The CNA staff did not use EBP PPE while performing these cares and transfers. On a later observation, CNA staff again assisted the resident with undressing and preparing for wound treatment while only wearing gloves and not EBP PPE. RN staff then provided treatment to the resident’s denuded areas and also treated the stage 3 left posterior thigh pressure injury not as ordered. The RN stated she was only performing morning treatment to the denuded areas and was unsure about the wounds, and the wound nurse later stated the resident should have EBP in place and staff should have been using EBP PPE due to the pressure injuries. The wound nurse also noted there was no PPE available by the room and no EBP sign on the door, and the DON later stated the resident required EBP and believed it had been removed after healing and not put back into place.
Failure to Offer and Document Influenza Immunizations
Penalty
Summary
The facility failed to develop and implement policies and procedures for influenza and pneumonia vaccinations when it did not offer the influenza immunization to 2 of 5 residents reviewed for immunizations. The facility policy stated that all residents were to receive the influenza vaccine annually between October 1 and mid-November, and residents admitted during the winter months were to receive the vaccine at admission unless there was a medical contraindication. The policy also required documentation of refusal in the nurse's notes, including that the resident was informed of the risks, with refusal tracked on the MAR for follow-up. Record review showed no documentation that R5 or R16 received the influenza vaccine, were educated about the benefits and potential side effects, or had the vaccine withheld due to medical contraindication or refusal. R5 was admitted with acute respiratory failure with hypoxia and unspecified asthma, and R16 was admitted with dyspnea, emphysema, and chronic respiratory failure with hypoxia. During interview, the DON stated the facility would try to locate correspondence showing R5 was offered the vaccine and stated R16 was not offered the influenza vaccine because the resident was admitted after the facility's influenza vaccine clinic, despite the facility policy stating residents admitted from October 1 through March 31 were to receive the vaccine on admission.
Failure to Offer and Document COVID-19 Vaccination for a Resident
Penalty
Summary
The facility did not offer the COVID-19 immunization to one resident, R16, and did not document whether the vaccine was offered and declined. R16 was admitted with diagnoses of dyspnea, emphysema, and chronic respiratory failure with hypoxia. On review of the electronic medical record, there was no documentation that R16 received education about the benefits, risks, or potential side effects of the COVID-19 vaccine, and no documentation that the resident received the vaccine, had a medical contraindication, or refused it. The facility policy stated that when COVID-19 vaccination is available, each resident is to be offered the vaccine unless medically contraindicated or already immunized, and that the resident or representative is to receive education before consent is requested. During interview, the DON stated R16 was not offered the COVID-19 vaccine because the resident was admitted after the facility's vaccine clinic. Surveyor review noted there was no documentation of education provided and no signed declination form or other record showing R16's COVID-19 vaccine status.
Failure to Report Allegations of Misappropriation and Neglect
Penalty
Summary
The facility did not ensure allegations of misappropriation of resident funds and neglect were reported to the State Survey Agency as required. The facility’s Resident Safety Abuse Policy stated that alleged violations involving abuse, neglect, exploitation, and misappropriation of resident property must be immediately reported to the administrator, and that the administrator must report reasonable suspicion of a crime to the State Agency and law enforcement, with investigation results reported to the State Survey Agency within 5 working days. For one resident, the resident told staff and later told the surveyor that money was missing after a withdrawal of $110, stating approximately $60 was missing and that the issue had been reported to a staff member. The resident’s guardian said they were unaware of any missing money. The Nursing Home Administrator acknowledged awareness of the allegation but said it was not reported because the resident was confused and uncertain about how much was missing, and because the resident had a history of false accusations. The administrator also stated the guardian did not think anything happened. For a second resident, the facility had a grievance investigation related to a fall and allegations that staff refused to send the resident to the hospital. The resident had a BIMS score of 14 and intact cognition on the quarterly MDS. The investigation documents showed APS involvement, record review, and a conclusion that the grievance was not confirmed. During interview, the administrator stated APS contacted him about the complaint, that he reviewed the record, and that he did not interview staff. He said he did not believe the allegation should have been sent to the State Agency because it could not be verified and he questioned the validity of the allegation.
Failure to Thoroughly Investigate Allegations of Missing Funds and Neglect
Penalty
Summary
The facility did not thoroughly investigate allegations involving potential misappropriation of resident funds and neglect. The facility’s Resident Safety Abuse Policy stated that all alleged violations would be thoroughly investigated, that all witnesses or involved parties would be interviewed, and that the facility must have evidence that all alleged violations are thoroughly investigated. However, the record showed that the facility did not complete a full investigation into a missing money allegation made by R19 and did not thoroughly investigate an allegation of neglect involving R10. R19, whose quarterly MDS documented a BIMS score of 5 indicating severely impaired decision-making skills, told staff on 1/21/26 that money was missing. Later, R19 told the surveyor that approximately $60 was missing after withdrawing $110 and giving the money to a staff member described as "Red." The NHA acknowledged awareness of the allegation but stated it was not reported or investigated because R19 was confused and uncertain about the amount missing, and because R19 had a history of false accusations. The facility documentation reviewed showed only one staff statement and one statement from R19’s guardian, with no additional staff interviews or statements from other residents. For R10, whose quarterly MDS showed a BIMS score of 14 with intact cognition and no behaviors or rejection of care, the facility provided a grievance investigation document dated 11/25/2025, but the report indicates the allegation of neglect directly affecting R10 was not thoroughly investigated.
Failure to Designate Director of Food and Nutrition Services
Penalty
Summary
The facility failed to designate a Director of Food and Nutrition Services, which is a requirement for ensuring that food is prepared, stored, and served in a sanitary manner. During an initial tour of the dietary department, it was discovered that there was no current Dietary Manager or Director of Food Services. Cook1 and Dietary Aid1 confirmed the absence of a supervisor, noting that a previously hired Director had quit, leaving the position vacant. The Corporate Clinical Consultant and the Administrator acknowledged the lack of a designated Director and mentioned ongoing recruitment challenges. Cook1, who was previously designated as the interim Director, did not meet the qualifications required for the role and had discontinued a relevant course. The Registered Dietitian (RD) provided clinical nutrition services but did not inspect the kitchen for sanitation issues, visiting the facility only once a week and sometimes virtually. The RD's limited hours and focus on clinical services left a gap in oversight for the dietary department's operations. The facility's job description for the Food Service Manager requires a Certified Dietary Manager, a qualification that Cook1 did not possess. This deficiency had the potential to affect all 41 residents in the facility by increasing the risk of foodborne illness due to inadequate supervision and management of food services.
Dishwasher Sanitizer Level Deficiency
Penalty
Summary
The facility failed to maintain the sanitizer level in the low temperature dishwasher at the required level to ensure proper sanitation of dishes. On the morning of October 15, 2024, a Dietary Aid (DA1) checked the chlorine sanitizer level using a test strip, which did not change color, indicating a zero parts per million (ppm) level. Despite this, DA1 proceeded to wash breakfast dishes without the necessary sanitizer level. Later that day, during lunch, DA1 was observed running soiled plates through the dishwasher and again tested the sanitizer level, which remained at zero ppm. DA1 continued to use the dishwasher despite the inadequate sanitizer level. The facility's policy, titled 'Dish Machine - Low Temperature/Chemical Status Procedure,' requires the chlorine level to be between 50 ppm and 100 ppm. The policy also mandates that if the chlorine level is not within acceptable limits, the problem should be fixed immediately, and the dish machine should not be used until the issue is resolved. The Administrator was informed of the deficiency and verified the zero ppm level, instructing the dietary staff to cease using the dishwasher until the problem was addressed. The failure to maintain the appropriate sanitizer level had the potential to result in foodborne illness or the spread of infections among all 41 residents in the facility.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for its residents, as evidenced by multiple observations of unsanitary conditions in resident bathrooms. In the shared bathroom of two residents, an unlabeled urinal was repeatedly found on the floor, and the call light cord was soiled with a brown substance. Additionally, a soiled incontinence brief was observed on the bathroom floor. One resident was cognitively intact and independent with toileting, while the other required moderate assistance and was frequently incontinent. These conditions were verified by the Social Service Director and the Maintenance Director. In another shared bathroom, a strong smell of urine was present, the floor was sticky, and a brown smear was noted on the wall. The call cord was also soiled. Both residents using this bathroom were capable of independent bathroom use, although one was severely cognitively impaired and required supervision for toileting. Furthermore, a resident reported a loose toilet seat and a soiled privacy curtain in her previous room, which were not addressed before another resident moved in. The facility's housekeeping policies required daily cleaning and reporting of maintenance issues, but these were not adhered to, leading to the observed deficiencies.
Inaccurate MDS Assessment Due to Omission of Feeding Tube Documentation
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident, who was identified as having a feeding tube since admission. The resident's medical records indicated a diagnosis of gastrostomy status, yet the MDS assessments conducted on three separate occasions did not document the presence of the feeding tube in Section K. This oversight was confirmed during interviews with the MDS Coordinator and the Director of Nursing (DON), both of whom acknowledged that the feeding tube should have been coded in the MDS assessments. The MDS Coordinator admitted that the feeding tube had been present since the resident's admission, although the resident did not receive nourishment through it. Despite this, the RAI manual, which was used to complete the MDS forms, clearly defines the need to document the presence of any feeding tube. The failure to accurately code the MDS assessments could lead to inaccurate assessment and care planning for the resident, as the feeding tube was not documented as required.
Lack of Physician's Order for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter had a physician's order for its use. This deficiency was identified for a resident diagnosed with neurogenic bladder, who was observed with urinary catheter tubing visible from the bottom of his pant leg, connected to a urinary collection bag. The resident's care plan noted the presence of a Foley catheter due to a spinal cord injury and neurogenic bladder, with instructions to change the catheter as needed and maintain equipment patency. However, the physician's orders lacked specific details such as the type of catheter, diameter size, balloon size, frequency of changing the catheter, and interventions to maintain patency. Interviews with the MDS Coordinator and the Director of Nursing confirmed the absence of a physician's order for the indwelling urinary catheter and the necessary interventions for care by the nursing staff. The facility's policy on catheter management requires a medically justified order for the use of an indwelling catheter, which was not present in this case. The deficiency was further supported by a review of a clinical nursing textbook, which emphasizes the need to review healthcare provider orders after identifying a resident.
Lack of Physician's Order for Feeding Tube Care
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube had a physician's order for the care and management of the feeding tube. The resident, identified as having a medical diagnosis of gastrostomy status and a history of severe protein malnutrition, was documented in the care plan as having an alteration in nutrition and dysphagia due to a failed swallow study. Despite these conditions, the resident's Medication Administration Record (MAR) for June and October 2024 indicated an intervention to flush the feeding tube with 120 milliliters of water daily, yet there was no corresponding physician's order documented in the electronic medical record. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed the absence of a physician's order for the daily flushing of the feeding tube. The registered nurse acknowledged that the evening shift performed the flush as listed on the MAR, and the Director of Nursing confirmed that there should have been an order for this procedure. The facility's policy on gastric feeding tubes also emphasized the need for consistency with physician's orders, highlighting the deficiency in adhering to established protocols.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure that a resident, identified as R41, received his medication as prescribed. During an observation, a pill was found in a medication cup on R41's bedside table, indicating that the medication had not been administered by the nurse. R41 confirmed that he had not been awakened by the night shift nurse to receive his medication and had not been given any medication earlier that morning. This oversight was contrary to the facility's policy, which requires that drugs be administered by the nurse until the care planning team assesses the resident's ability to self-administer medication. R41, who was admitted to the facility with a diagnosis of diabetes, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Despite this, there was no assessment conducted for R41's ability to self-administer medication, as noted in the electronic medical record. The Director of Nursing confirmed that it was not acceptable for a nurse to leave medication in a resident's room and emphasized that the nurse should witness the resident taking the medication before signing the Medication Administration Record (MAR). The failure to administer the medication as required had the potential to place the resident at risk for health decline.
Controlled Substances Not Properly Secured and Documented
Penalty
Summary
The facility failed to ensure that controlled substances were properly secured and documented, leading to potential drug diversion. The policy required controlled substances to be double-locked and counted by two nurses at each shift change, with both nurses signing the individual controlled substances count sheets and the Master Controlled Substance record. However, the review of the controlled substance count sheets revealed missing signatures for several dates, indicating that the counts were not verified. Additionally, the Master Control Substance record had multiple blanks where signatures and the number of cards should have been indicated. This issue affected three residents, as their individual count sheets for narcotics were missing the administering nurse's signature, although the Medication Administration Records (MARs) showed that the narcotics were administered. During an interview, an LPN admitted to not signing the controlled substances she had administered and assumed that the previous shift nurse had forgotten to sign them out. The LPN did not verify this by checking the MAR or notify the DON of the discrepancy. The DON confirmed that she was not informed about the missing signatures and acknowledged that an incorrect count could indicate drug diversion. The DON also noted that the Master Control Substance record should have been signed by the nurses coming on and going off duty, but there were multiple omissions of signatures. Additionally, an observation revealed that the medication room's refrigerator, which contained Ativan, was not double-locked as required by the facility's policy. An RN admitted to forgetting to lock the refrigerator after accessing it earlier in the shift. The DON and the Administrator confirmed that the medication room and refrigerator should be under double lock, and the failure to do so was against their policy.
Deficiency in Staff Training for Chemotherapy Infusion Pump
Penalty
Summary
The facility failed to ensure that staff were adequately prepared and educated to care for a resident with a portable infusion pump delivering chemotherapy drugs through a surgically implanted port. This deficiency was identified through staff interviews, record reviews, and document reviews. The resident, who had a medical history including chronic viral hepatitis C, HIV disease, and a new rectal cancer diagnosis, returned from a clinic appointment with an infusion pump. However, the nursing progress notes lacked documentation of the presence of the pump until several days later, and there was no evidence that staff were informed or trained on how to manage the pump or the chemotherapy drugs. Interviews with staff, including an LPN and the DON, revealed that they were not educated about the chemotherapy drug infusion or the necessary precautions. The Corporate Clinical Consultant confirmed that the staff had not been educated prior to the resident's return with the pump, and the facility assessment did not include provisions for caring for residents receiving on-site chemotherapy. The physician's order also lacked instructions for handling hazardous material in the event of a leak or spill. This lack of preparation and education posed potential harm and injury risks to both residents and staff.
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 419 citations issued within 25 miles in the last 12 months — including the 17 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 Kenosha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avina Of Kenosha | 1.8 mi | ★★★★★ | 2 | 0 |
| Waters Edge Health And Rehabilitation Center | 1.8 mi | ★★★★★ | 33 | 3 |
| Sheridan Health And Rehabilitation Center | 1.9 mi | ★★★★★ | 22 | 0 |
| Brookside Care Center | 2 mi | ★★★★★ | 0 | 0 |
| Avina On 32nd | 2.4 mi | ★★★★★ | 3 | 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.