Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Complete Care At Care Age during CMS and state inspections, most recent first.
Staff delivered meal trays with uncovered desserts and beverages to residents eating in their rooms, contrary to facility policy requiring food and drinks to be covered during transport. Multiple staff, including CNAs and RNs, were observed preparing and carrying uncovered items down hallways to residents, potentially affecting a significant portion of the facility's population.
A resident with a history of falls and osteoporosis was transferred by a single CNA using a sit-to-stand lift, contrary to her care plan requiring two staff. The lift malfunctioned, resulting in the resident being left in a compromised position and subsequently sustaining a hip fracture. Staff failed to promptly report the incident, did not perform or document a thorough RN assessment, omitted vital signs, and did not communicate the full details to the provider, leading to delayed medical intervention.
Three residents with or at risk for pressure injuries did not receive consistent and necessary interventions, such as offloading boots and regular turning and repositioning, as required by their care plans. Staff were observed not following prescribed protocols, documentation was incomplete or missing, and timely wound assessments were not performed, resulting in the development and worsening of pressure injuries.
A resident who required a two-person assist with a sit-to-stand lift was transferred by a single CNA, resulting in a fall and a right femoral fracture. The incident was not promptly reported or assessed according to facility policy. Additionally, staff charged a motorized wheelchair in a resident's room and electric patient lifts in hallways, contrary to facility policies and safety recommendations.
Surveyors identified multiple deficiencies in food safety and sanitation, including lack of proper monitoring of the chemical dishwasher's sanitizing concentration, staff not wearing required hair or beard restraints in food prep areas, and improper labeling and dating of opened or expired food items. These failures had the potential to affect all residents in the facility.
Multiple residents reported that their meals, especially meat dishes, were too tough to chew and often served cold or lukewarm, particularly when delivered to rooms. Surveyors found food temperatures below required standards for hot foods and above for cold items, and observed residents struggling to eat the provided meals. Staff cited a shortage of heat-retaining equipment and improper cooking methods as contributing factors to the deficiency.
Staff failed to consistently perform proper hand hygiene during wound care and medication administration for several residents. In multiple cases, a nurse practitioner and LPNs did not cleanse hands after removing gloves and before donning new gloves or after handling contaminated items, contrary to facility policy. These lapses were observed during wound care for residents with pressure ulcers and during blood glucose testing, with staff confirming in interviews that correct procedures were not followed.
Two residents with indwelling catheters did not receive proper care to prevent UTIs, as one had a catheter bag in contact with the floor and another received catheter/peri care from a CNA who failed to perform hand hygiene between glove changes and mixed clean and soiled washcloths in the same bags, contrary to facility policy and infection control standards.
Three residents were repeatedly served foods they disliked or could not safely consume, despite their preferences and dietary restrictions being documented. One resident with malnutrition and no teeth was given tough meats and vegetables, another with Crohn's disease received restricted vegetables, and a third continued to receive gravy despite a documented dislike. These failures were observed and confirmed through interviews and record reviews, showing a lack of adherence to resident food preferences and dietary needs.
The facility did not ensure that residents were clinically assessed and approved for self-administration of medications, resulting in multiple instances where medications were left at bedside without proper assessment or physician orders. In several cases, medications were left out for extended periods, and required nurse follow-up was not performed, contrary to facility policy and resident care plans.
Three residents prescribed melatonin for sleep issues did not have required sleep assessments or sleep monitoring documented, despite facility policy mandating such evaluations for psychotropic medication use. The DON confirmed that sleep assessments and monitoring were not routinely performed for residents receiving sleep aids.
Two residents experienced significant medication errors when one did not receive prescribed evening doses of Carbidopa-Levodopa for Parkinson's Disease, and another missed a scheduled dose of IV Meropenem for a wound infection. In both cases, staff confirmed the omissions, and facility policy was not followed regarding medication administration and documentation.
The facility failed to provide adequate pharmaceutical services, as staff did not consistently document medication administration times immediately after administering narcotic pain medications to residents. This led to potential risks of medication errors due to late documentation, with some instances of documentation occurring hours after administration. Interviews with staff revealed that while the policy required immediate documentation, delays occurred due to various reasons, highlighting a deficiency in adherence to the facility's policy and state regulations.
A resident alleged that a CNA caused a skin tear by grabbing her arm, but the facility failed to report this abuse allegation to the State agency within the required timeframe. The incident was initially reported as a skin tear from removing a sweatshirt, and the specific abuse claim was not communicated to the NHA or State agency until two days later, despite facility policy requiring immediate reporting.
A resident's care plan was not revised after an incident where a CNA allegedly caused a skin tear by grabbing the resident's wrist. The resident, who requires substantial assistance for daily activities, had specific preferences and routines that were not documented in the care plan until prompted by a surveyor. The facility's policy mandates care plan revisions upon status changes, which was not followed in this case.
A resident accused a CNA of slapping her, but the LPN did not immediately report the allegation to administration, resulting in the CNA not being removed from the resident care area immediately. The delay in action had the potential to affect 19 residents. The resident involved had severe cognitive impairment and multiple diagnoses.
A resident with severe cognitive impairment accused a CNA of slapping her, but the LPN did not immediately report the allegation to the administration or law enforcement. The incident was only reported later in the morning, delaying the necessary investigation and response actions.
The facility failed to address and follow up on grievances discussed during Resident Council meetings, as multiple residents expressed concerns that their issues were not resolved or followed up on. The facility did not have documented grievance forms or resolutions, and Resident Rights and other important information were not reviewed during meetings.
A resident with dementia did not receive a replacement hearing aid after losing the original one. Despite an audiology consult recommending medical clearance for a new hearing aid, the facility failed to obtain the clearance and follow up on the order. Multiple staff members were unaware of the status, leading to the resident being without a hearing aid for an extended period.
A resident with multiple diagnoses, including dementia, was prescribed Seroquel without obtaining consent from the POA or monitoring for side effects until months later, after a surveyor's inquiry. The facility staff acknowledged the oversight and took steps to address it.
Uncovered Food and Beverages Served to Residents in Rooms
Penalty
Summary
Staff failed to serve food and beverages to residents in accordance with professional standards and facility policy, which requires that prepared food be transported in covered containers. Observations revealed that meal trays delivered to residents' rooms contained uncovered dessert items and beverages. Specifically, a resident received a lunch tray with an uncovered bowl of chocolate cake and coffee without a lid, which had been prepared at the nurses' station and carried down the hallway uncovered. During breakfast service, staff were observed pouring beverages such as orange juice, coffee, and milk into cups and glasses at the nurses' station and then transporting them uncovered to residents' rooms. Interviews with the District Dietary Manager confirmed that the expectation is for all food and beverages transported from the cart down the hall to be covered, and that individual beverage containers should be opened and poured in the resident's room. Despite this, multiple staff members, including CNAs, RNs, and other personnel, were observed passing trays with uncovered items to residents in their rooms. The deficiency potentially affected 45 of 67 residents who eat their meals in their rooms.
Failure to Provide Timely Assessment and Communication After Mechanical Lift Incident
Penalty
Summary
A deficiency occurred when a resident with multiple comorbidities, including osteoporosis and a history of falls, experienced a significant change in condition following an incident involving a sit-to-stand lift. The resident, who required two staff for transfers per her care plan, was transferred by a single CNA using the lift. During the transfer, the lift's battery died, resulting in the resident being left in a squatting position with her buttocks on the foot pads of the lift. The CNA, acting alone, attempted to move the resident from the compromised position to her wheelchair and then to bed, without waiting for a nurse assessment. This incident resulted in a hip fracture for the resident. Following the incident, staff failed to follow established protocols and professional standards of practice. The event was not immediately or accurately reported to the oncoming shift or to the resident's provider, and critical details such as the change of plane and the resident ending up on the floor were omitted. There was no thorough or timely RN assessment performed after the incident, despite the resident reporting escalating pain levels (up to 9 out of 10) and visible changes in the appearance and positioning of her leg. Vital signs were not obtained or documented at the time of the incident or during subsequent pain episodes, and changes in the resident's condition, such as internal rotation of the lower extremity, were not recorded in the medical record. Communication breakdowns further contributed to the deficiency. The provider was not informed of the true nature of the incident, which delayed appropriate medical intervention and diagnostic testing. Staff interviews revealed a lack of understanding and adherence to post-fall protocols, including the requirement for RN assessment before moving a resident after a fall or change of plane. Documentation was incomplete and delayed, with late entries and missing assessments, and staff failed to ensure that all relevant information was communicated to the provider and documented in the resident's record.
Failure to Prevent and Manage Pressure Injuries Due to Inconsistent Implementation and Documentation
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services to prevent the development and worsening of pressure injuries (PIs) and to promote healing, as evidenced by the care of three residents. One resident with multiple comorbidities, including dementia, diabetes, and chronic kidney disease, developed an unstageable pressure injury to the right heel. Despite being care planned for bilateral heel boots at all times and regular turning and repositioning, documentation showed inconsistent implementation of these interventions. The resident was observed without required offloading boots while seated in a Broda chair, and staff interviews confirmed a lack of awareness and adherence to the care plan. Additionally, turning and repositioning were not consistently documented, and the facility did not have a policy for this intervention at the time of the deficiency. Another resident, admitted with a pressure injury on the coccyx and identified as at risk for further pressure injuries, developed an unstageable pressure injury on the left heel. The care plan required Prevalon boots at all times except during therapy, but the resident was observed without the boots and with heels in direct contact with the mattress. The Medication Administration Record and Kardex did not reflect the intervention, and staff were unaware of the requirement, indicating a breakdown in communication and care planning. A third resident did not receive a timely assessment of a pressure injury, with five days elapsing before the wound was evaluated. Facility policies required accurate and timely assessment and documentation of pressure injuries, including measurements and wound characteristics, but these were not followed. The deficiencies were substantiated by direct observations, record reviews, and staff interviews, which revealed lapses in implementing and documenting evidence-based interventions for pressure injury prevention and management.
Failure to Prevent Accidents and Ensure Safe Equipment Use
Penalty
Summary
A deficiency occurred when a resident who required a two-person assist with a sit-to-stand lift was transferred by a single CNA, contrary to the resident's care plan and facility policy. During the transfer, the lift lost battery power, resulting in the resident being lowered to a squatting position and ultimately sitting on the ground, constituting a change of plane/fall. The CNA then assisted the resident off the floor and into her wheelchair without notifying a nurse or obtaining an RN assessment as required by facility policy. The incident was not immediately reported to the floor nurse or oncoming shift, and subsequent communication among staff failed to ensure timely notification and assessment. The resident was later found to have sustained an intertrochanteric right femoral fracture as a result of the incident. The facility's policies required two staff members for all mechanical lift transfers and immediate reporting and assessment following any fall or change of plane. However, the CNA involved in the incident did not follow these protocols, and other staff members who became aware of the event also failed to report it promptly. The facility's investigation revealed that the emergency lowering feature of the lift was not well understood or effectively used by staff, and that staff had not received adequate competency checks or training on lift operation and emergency procedures. Additionally, the facility did not follow its own fall prevention and post-fall assessment protocols, as the resident was moved and transferred multiple times without a nurse's assessment. Further deficiencies were identified regarding the charging of motorized wheelchairs and electric patient lifts. Staff routinely charged a resident's motorized wheelchair in her room, despite facility policy requiring charging in a ventilated, approved area outside resident rooms. Electric patient lifts were observed being charged in hallways, which is inconsistent with safety recommendations for sealed lead acid batteries, as outlined in the manufacturer's safety data sheet. Staff interviews confirmed that these practices were standard, and facility leadership was either unaware of or did not express concern about the safety implications of these charging locations.
Deficient Food Safety and Sanitation Practices in Dietary Services
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, as evidenced by multiple observations and staff interviews. The facility did not have a system in place for manually monitoring the internal concentration of the chemical dishwasher, which is necessary for proper sanitization. Staff were observed to be recording dishwasher temperatures, despite the dishwasher being a chemical sanitizing type, and the temperature logs did not reflect the actual temperatures observed, which were consistently below the required levels. Additionally, the test strips used to monitor chemical concentration were expired, and staff were unsure of the correct procedures for monitoring the dishwasher's effectiveness. Staff in the food preparation areas were observed not wearing appropriate hair restraints, including hairnets and beard nets, despite facility policy requiring all hair to be covered when in the kitchen. Multiple staff members, including dietary managers and aides, were seen in the kitchen and food prep areas with uncovered hair or facial hair while handling food and clean dishes. Staff interviews confirmed a lack of consistent adherence to the hair restraint policy. Food storage practices were also found to be deficient. Surveyors observed multiple instances of opened food items in refrigerators and freezers that were not labeled or dated, as well as food items that were past their expiration or use-by dates. Staff acknowledged that all opened food should be labeled and dated, and that expired food should be discarded, but these practices were not consistently followed. These deficiencies had the potential to affect all 57 residents residing in the facility.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at safe and appetizing temperatures, as required by facility policy. Multiple residents reported that their meals, particularly meat dishes, were too tough to chew and often served cold or lukewarm, especially when meals were delivered to resident rooms. Surveyors observed that food temperatures on test trays were below the required threshold for hot foods, with mixed vegetables at 122°F and beef with gravy at 130°F, both below the facility's policy of holding hot foods at 135°F or greater. Cold items, such as milk and cranberry juice, were also served above the required cold holding temperature, with milk at 52.1°F and juice at 51°F, exceeding the policy limit of 41°F or below. Residents with varying cognitive abilities, including those with moderate cognitive impairment and diagnoses such as protein-calorie malnutrition and dementia, voiced concerns about the palatability and temperature of their meals. Several residents indicated that the meat was too tough to chew or swallow, and that hot foods were often served cold, particularly for those eating in their rooms. Surveyors directly observed residents struggling to eat the provided meat, and noted that some residents resorted to bringing in outside food due to dissatisfaction with the facility's meals. Staff interviews revealed that there were operational issues contributing to the deficiency, such as a shortage of heat-retaining cambrio tops and bottoms, resulting in inadequate temperature maintenance during meal delivery. The dietary staff acknowledged that the beef was overcooked and dry due to being cooked in two separate stages, contrary to the recipe instructions. The facility's failure to maintain appropriate food temperatures and palatability affected all sampled and supplemental residents reviewed for food quality, as confirmed by both resident interviews and direct surveyor observations.
Failure to Perform Proper Hand Hygiene During Resident Care
Penalty
Summary
Surveyors identified that the facility failed to implement and maintain an effective infection prevention and control program, specifically regarding hand hygiene practices during wound care and medication administration. Staff did not consistently perform hand hygiene as required by facility policy and accepted standards of practice. The facility's own policies state that hand hygiene must be performed after removing gloves and before donning new gloves, as well as after handling contaminated items or performing procedures such as wound care and blood glucose testing. In multiple observed instances, a nurse practitioner performed wound care on two residents with pressure ulcers and failed to perform hand hygiene after removing gloves and before putting on new gloves, despite handling wounds and dressings. The nurse practitioner stated that she only washes hands when leaving the resident's room and believed that removing gloves was sufficient to remove contamination. The Director of Nursing confirmed that hand hygiene should have been performed after glove removal and before donning new gloves, in accordance with facility policy. Additional observations included a LPN performing a blood glucose test and then touching the medication cart without removing gloves or performing hand hygiene, as well as another LPN failing to remove gloves and cleanse hands after removing a wound dressing and before cleansing the wound. This LPN also touched the outside of a contaminated gown with bare hands during PPE removal. Interviews with staff and the Director of Nursing confirmed that these actions were not consistent with facility policy or infection control standards.
Deficient Catheter Care and Infection Control Practices
Penalty
Summary
Two residents with indwelling urinary catheters did not receive appropriate care and services to prevent urinary tract infections, as evidenced by direct observations and staff interviews. One resident was observed multiple times with a catheter bag dragging on or resting in contact with the floor while being transported in a wheelchair and during wound care. Multiple staff members, including an LPN, the Nursing Home Administrator, and the Director of Nursing, acknowledged that catheter bags should not be in contact with the floor, in accordance with facility policy. Another resident received catheter and peri care from a CNA who failed to maintain proper infection control practices. The CNA placed soiled washcloths in the same garbage bags as clean washcloths, only separating them by keeping dirty ones in one corner and clean ones in another. The CNA also failed to perform hand hygiene between removing soiled gloves and donning new gloves during the care process, despite facility policy requiring hand hygiene at these points. The CNA later acknowledged that hand hygiene should have been performed and that mixing clean and soiled washcloths could be a risk for cross-contamination. Facility policies reviewed by the surveyor required catheter care every shift, proper hand hygiene before and after glove use, and separation of clean and soiled items to prevent infection. The Director of Nursing confirmed that hand hygiene should be performed after doffing and before donning gloves, and that clean and dirty washcloths should be kept in separate bags. These lapses in infection control and catheter care were observed and confirmed through staff interviews and record review.
Failure to Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to provide food that accommodated resident preferences and dietary needs for three residents, as evidenced by direct observations, interviews, and record reviews. One resident with moderate cognitive impairment and a history of malnutrition and dysphagia was repeatedly served vegetables and tough meats, despite these being listed as disliked foods on his meal ticket and his inability to chew them. The resident had communicated these preferences to staff and the dietician, but the issue persisted, resulting in the resident refusing meals and expressing frustration over not being heard. Another resident with Crohn's disease and a low residue diet order was served mixed vegetables, including beans, which were specifically restricted on her meal ticket. The resident, who was cognitively intact, reported that she sometimes received foods incompatible with her medical condition, and this was confirmed by observation and staff interview. The care plan for this resident did not specify which foods to avoid or safe alternatives, contributing to the dietary errors. A third resident, who had a documented dislike of gravy and a preference for Cheerios at breakfast, continued to receive gravy on her meals and had to repeatedly request her preferred breakfast cereal. Despite her dislikes being clearly listed on her meal ticket, staff continued to serve her foods she did not want, leading to ongoing frustration. These incidents demonstrate a failure to honor resident food preferences and provide appealing alternatives as required by facility policy and resident rights.
Failure to Assess and Approve Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were clinically assessed and approved for self-administration of medications, as required by policy. In one instance, a resident with diagnoses including generalized anxiety disorder, polyosteoarthritis, and congestive heart failure was observed with a cup of medications left on his bedside table for independent consumption. There was no physician's order, care plan, or assessment indicating that this resident was safe to self-administer medications. Both the LPN and DON confirmed that no assessment or order was in place, despite the resident regularly taking medications independently. Another resident was found with multiple medication containers at bedside and scheduled medications left out for more than one hour, contrary to her self-administration assessment, which only permitted Lactaid at bedside and required nurse follow-up within one hour. Observations revealed that medications, including pills from the previous evening, remained at the bedside and on the floor, and the nurse did not follow up as required. The DON confirmed that only Lactaid should be at bedside and that the nurse failed to ensure timely medication administration and removal of unauthorized medications. A third resident was observed with a Combivent inhaler at bedside on multiple occasions, but there was no assessment completed to determine if self-administration was clinically appropriate. Both the LPN and DON confirmed that this resident had not been assessed for self-administration, and facility policy dictates that medications should not be left at bedside without such an assessment. These findings demonstrate a pattern of noncompliance with the facility's own policy regarding the clinical assessment and approval process for resident self-administration of medications.
Failure to Complete Sleep Assessments and Monitoring for Residents on Melatonin
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was developed and implemented for residents prescribed sleep aids, specifically melatonin. Three residents who were prescribed melatonin for sleep-related issues, such as difficulty sleeping, sleep hygiene, and insomnia, did not have a sleep assessment completed or any sleep monitoring documented in their medical records. This lack of assessment and monitoring was identified through both interview and record review. The facility's policy on the use of psychotropic medications requires a documented clinical rationale for medication use, including an assessment of the resident's condition, evaluation of non-pharmacological approaches, and ongoing documentation of the resident's response to the medication. Despite these policy requirements, the Director of Nursing confirmed that sleep assessments and monitoring were not routinely conducted for residents taking sleep aids, resulting in the absence of necessary documentation and evaluation for the affected residents.
Medication Administration Errors Result in Missed Doses for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first case, a resident with Parkinson's Disease, who had previously been assessed as unable to self-administer medications due to tremors, did not receive her evening doses of Carbidopa-Levodopa as prescribed. Medications were found on her bedside table and on the floor under her wheelchair, and both the resident and staff confirmed that the evening medications had not been taken. The facility's policy defines omitted medications as a medication error, and staff interviews confirmed that the resident was not supposed to self-administer her medications at this time. In the second case, another resident with a recent surgical procedure and a wound infection did not receive a scheduled dose of intravenous Meropenem, an antibiotic ordered to treat the infection. The medication administration record (MAR) for this resident showed a blank entry for the missed dose, and multiple staff members, including an LPN, the ADON, and the DON, confirmed that a blank on the MAR indicates the medication was not given. There was no documentation to support that the dose was administered as ordered. Both incidents demonstrate a failure to follow physician orders and facility policy regarding medication administration and documentation. The omissions were identified through direct observation, interviews with staff and residents, and review of medical records and facility policies. The facility did not ensure that medications were administered as prescribed or that proper documentation was maintained, resulting in significant medication errors for both residents.
Inadequate Pharmaceutical Services and Documentation Delays
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by the lack of consistent documentation of medication administration times. This deficiency was observed in five residents who had medical doctor orders for narcotic pain medication. Facility staff did not consistently document the administration time of the pain medication directly after administering it, as outlined in the facility policy. This late documentation could result in the duplication of pain medication administration, potentially leading to medication errors. For instance, one resident with a diagnosis of dementia and recent hospitalization for sepsis and fractures had multiple instances where the administration of Oxycodone was documented hours after it was given. In some cases, the delay in documentation was as long as nine hours. Another resident with a diagnosis of infection and inflammatory reaction due to a knee prosthesis had duplicate medical doctor orders for Oxycodone, and staff documented the administration of the medication on both orders, which could cause confusion and the possibility of administering more medication than prescribed. Interviews with facility staff, including LPNs, RNs, and the Director of Nursing, revealed that while the policy required immediate documentation of medication administration, there were instances where documentation was delayed due to staff being pulled away for other tasks or forgetting to document until later. The Director of Nursing acknowledged the issue and expressed concern about the potential for medication errors due to the late documentation. Despite the facility's policy and state regulations requiring immediate documentation, the practice was not consistently followed, leading to the identified deficiency.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R2, within the required timeframe. On December 7, 2024, a skin tear was observed on R2's left wrist, which was initially reported by a CNA to an LPN as occurring while removing R2's sweatshirt. However, R2 later alleged that the skin tear resulted from the CNA grabbing her arm. This allegation was communicated to the Director of Nursing (DON) but was not reported to the State Survey Agency or the Nursing Home Administrator (NHA) until December 9, 2024. The facility's policy mandates that all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury. Despite this policy, the DON did not report the allegation to the State agency, citing the need for further investigation due to R2's history of making accusations against staff. The NHA was not informed of the specific allegation of abuse until two days later, after R2's son contacted the facility. R2, who is cognitively intact with a BIMS score of 13, requires substantial assistance with daily activities and has a history of osteoarthritis, anxiety disorder, and other medical conditions. The failure to report the allegation promptly was attributed to miscommunication and assumptions made by the staff regarding the credibility of R2's claims and the necessity of further investigation before reporting to the appropriate authorities.
Failure to Revise Care Plan After Resident Incident
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R2, following an incident where a CNA allegedly grabbed the resident's wrist, resulting in a skin tear. The incident occurred on December 7, 2024, but the care plan was not updated to reflect the resident's preferences and needs until prompted by a surveyor on January 16, 2025. The facility's policy requires care plans to be reviewed and revised upon a resident's status change, which was not adhered to in this case. R2 has a medical history that includes osteoarthritis, anxiety disorder, hypertension, essential tremor, and depressive disorder. The resident requires substantial assistance for various activities of daily living, including toileting, mobility, and dressing. Despite these needs, the care plan did not initially include specific interventions to address R2's preferences, such as keeping the door open due to claustrophobia and the routine of walking back to bed with a walker after toileting in the evening. The deficiency was identified during a surveyor's observation and interviews with facility staff. The surveyor noted that the care plan lacked details on R2's preferences and routines, which could lead to misunderstandings among staff unfamiliar with the resident's care. The Director of Nursing admitted to delegating the task of updating the care plan but did not follow up to ensure it was completed, resulting in the oversight.
Failure to Immediately Remove CNA After Abuse Allegation
Penalty
Summary
The facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. On 4/2/24, a resident accused a Certified Nursing Assistant (CNA) of slapping her. The CNA reported this to a Licensed Practical Nurse (LPN), who did not immediately report the allegation to administration. As a result, the CNA was not removed from the resident care area immediately and was allowed to work the rest of the shift. This failure to act promptly had the potential to affect 19 residents on the 400 hallway. The facility's policy on Abuse, Neglect, and Exploitation, revised on 09/22/2023, mandates immediate protection of the alleged victim and removal of the accused staff member pending investigation. However, the LPN did not follow this policy, leading to a delay in the removal of the CNA. The Nursing Home Administrator and Director of Nursing confirmed that the CNA was only removed after an interview conducted at 6:35 AM, several hours after the initial allegation at 3:35 AM. The resident involved had severe cognitive impairment, as indicated by a BIMS score of 05, and was diagnosed with COPD, Dementia, Restlessness, Agitation, and a History of Falls.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and the State Survey Agency. A resident accused a Certified Nursing Assistant (CNA) of slapping her, and the CNA reported this to a Licensed Practical Nurse (LPN). However, the LPN did not immediately report the allegation to the administration, and law enforcement was not contacted to report this reasonable suspicion of a crime. The incident was only reported to the administration later in the morning, delaying the necessary investigation and response actions. The resident involved had a history of severe cognitive impairment, as indicated by a BIMS score of 05, and was admitted with diagnoses including COPD, dementia, restlessness, agitation, and a history of falls. The incident occurred during the night, and the resident continued to express that she had been hit, although no physical injuries were observed. The LPN believed the resident's behavior was consistent with her dementia and did not think anything had happened, which contributed to the delay in reporting the incident. The facility's policy required immediate reporting of all alleged violations to the administrator, state agency, adult protective services, and other required agencies, including law enforcement when applicable. Despite this policy, the LPN failed to follow the established procedures, and the administration was not informed until later. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed that the incident was not reported to the police, as they did not consider it a crime. The DON also noted that the LPN had received individualized abuse training on the day of the incident.
Failure to Address and Follow Up on Resident Council Grievances
Penalty
Summary
The facility failed to ensure grievances and recommendations discussed during Resident Council meetings were acted upon promptly and with feedback provided. Multiple residents expressed concerns that their grievances were not resolved or followed up on, as documented in the minutes of several Resident Council meetings. Specific grievances included issues with cleanliness, missing personal items, dietary staff not wearing hair nets, call lights not being answered, and food quality. The facility did not have documented grievance forms addressing these concerns or their resolutions, and there was no follow-up documentation in subsequent meeting minutes. The surveyor reviewed the facility's policy on Resident Council meetings, which mandates that the facility act upon concerns and communicate decisions to the Council. However, the surveyor found that the facility did not adhere to this policy. The Activity Director, who had been in the position for three months, confirmed that Resident Rights, the ombudsman, and how to contact the State Survey Agency were not reviewed during the meetings. The Nursing Home Administrator also confirmed the lack of documentation for resolving concerns from previous months. During interviews, residents with varying levels of cognitive function expressed that their concerns were not addressed or followed up on by the facility staff. The surveyor noted that the facility had recently started a new procedure for addressing concerns but had not yet implemented it effectively. The lack of documented resolutions and follow-up actions for grievances discussed in Resident Council meetings indicates a failure to comply with the facility's own policies and procedures, leading to the deficiency noted in the report.
Failure to Provide Hearing Aid for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain hearing ability. The resident, diagnosed with dementia, had an audiology consult on February 19, 2024, for a lost hearing aid. The consult recommended obtaining medical clearance for a comprehensive evaluation for hearing aids. However, as of March 20, 2024, the medical clearance had not been obtained, and the resident did not have a right hearing aid. The resident's care plan included several interventions related to communication and hearing aid use, but these were not effectively implemented due to the missing hearing aid. Multiple observations by the surveyor on March 18 and 19, 2024, confirmed that the resident was not wearing a hearing aid. Interviews with various staff members, including CNAs, LPNs, and the social worker, revealed a lack of follow-up and communication regarding the resident's hearing aid. The social worker had emailed about the issue on March 1 and March 14 but did not receive any response. The LPNs and the Director of Nursing were unaware of the status of the medical clearance and the hearing aid order, indicating a breakdown in the process of obtaining and following up on the necessary medical consult. The facility's policy stated that all residents should have access to hearing and vision services and receive adaptive equipment as indicated. Despite this policy, the resident's hearing aid was lost, and no effective steps were taken to replace it promptly. The lack of coordination and communication among the staff members contributed to the delay in obtaining the necessary medical clearance and the new hearing aid, resulting in the resident not having the required assistive device for an extended period.
Failure to Obtain Consent and Monitor Side Effects for Psychotropic Medication
Penalty
Summary
The facility did not ensure that potential side effects of psychotropic medications were monitored and consents were provided for a resident (R25) who was prescribed Seroquel. R25, who had diagnoses including a fractured patella, coronary artery disease, muscular dystrophy, anxiety, depression, and dementia, was admitted with moderate cognitive impairment and required substantial assistance with daily activities. On 12/18/2023, R25 received an order for Seroquel 25 mg twice daily for behaviors, but the consent for this medication was not obtained from the activated Power of Attorney (POA) until 3/19/2024, after the surveyor inquired about it. Additionally, no monitoring for potential adverse side effects of the Seroquel was documented until 3/19/2024. The deficiency was identified during a review of R25's medical records and interviews with facility staff. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were unable to provide a consent form for the use of Seroquel until after the surveyor's request. The Social Worker (SW) indicated that behavior meetings were held regularly to review residents on psychotropic medications, but it was the responsibility of the nurse or nurse manager to obtain consents and put in monitoring orders. The NHA acknowledged the oversight and conducted a facility-wide sweep to ensure all consents for psychotropic medications were obtained after the surveyor brought the issue to their attention.
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What surveyors actually found near you
We read the 751 citations issued within 25 miles in the last 12 months — including the 16 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 Brookfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Franciscan Woods | 0.7 mi | ★★★★★ | 22 | 0 |
| Aria Of Brookfield | 1.8 mi | ★★★★★ | 39 | 0 |
| Aria Of Waukesha | 3.4 mi | ★★★★★ | 20 | 1 |
| Congregational Home, Inc. | 4.3 mi | ★★★★★ | 0 | 0 |
| Lindengrove Waukesha | 5.8 mi | ★★★★★ | 20 | 1 |
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.