Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Grande Prairie during CMS and state inspections, most recent first.
Improper Hair Restraints During Food Preparation: The DM and dietary staff were observed preparing and handling food without beard restraints covering facial hair, and one aide wore a hat that did not fully restrain hair. Surveyors cited the Wisconsin Food Code requirement for hair and beard restraints, and the DM stated facial hair under a quarter inch did not need a beard restraint.
Inaccurate PBJ Staffing Submission: The facility did not submit accurate PBJ staffing data to CMS for a quarter in which the PBJ report showed excessively low weekend staffing. Review of weekend schedules showed CNAs and nurses were present on each shift, with call-ins filled by facility or agency staff, and the Scheduler, NHA, CNA, and LPN all stated staffing levels were adequate and weekends were not low staffed.
Expired stock medications and loose pills were found in multiple medication carts during surveyor observation. On one unit, several medications had expired or missing expiration dates, and staff stated they would discard them or add open dates when needed. In two other carts, 58 loose pills were found in one cart and 5 loose medications plus an expired bottle of liquid pain relief were found in another; the DON stated the facility did not know the expectation for loose pills in the cart.
Missed and Undocumented Tube Feedings: A resident with a gastrostomy tube and dysphagia had an order for nocturnal continuous enteral feeding, but surveyors observed the feeding bag nearly full on multiple occasions and found the pump was not running. Staff stated the resident was taken off the tube feed early because the resident was pulling at the tube, yet there was no documentation of the missed nutrition, no record of refusal, and no timely notification to the provider.
A facility failed to provide trauma informed care for 3 residents with PTSD by not developing person-centered care plans that identified triggers, individualized interventions, or monitoring related to their trauma histories. One resident with moderate cognitive impairment and another with intact cognition had documented past traumatic events, but staff said past trauma was not care planned unless it was recent or tied to current behaviors. The residents’ records contained assessments and other care plans for depression, anxiety, hallucinations, and behavior issues, but no trauma informed care plans for PTSD triggers or mitigation.
Two residents with complex medical and cognitive needs reported abuse by CNAs, but the facility failed to promptly investigate the allegations or remove the accused staff from resident care. Witnesses corroborated one resident's account of physical assault, yet the CNA continued working for weeks. In the other case, a resident's report of inappropriate touching was not thoroughly investigated, and the CNA remained on duty. The facility did not follow its abuse policy, resulting in residents not being protected from further potential harm.
A resident with multiple chronic conditions was physically and verbally abused by a CNA, resulting in injury and increased pain. Witnesses confirmed the CNA's aggressive actions, but the DON failed to investigate or report the incident as required by facility policy. The resident's medical needs following the incident were not promptly addressed due to delays in communication and lack of follow-up on medical records.
A resident assessed as needing bilateral enabler bars for bed mobility had only one enabler bar installed, despite care plan and assessment documentation indicating the need for both. During care, a CNA rolled the resident away from themselves, leading to a fall from bed and a hip fracture. Documentation and care planning were inconsistent, and proper supervision and assistive devices were not provided as required.
The facility failed to promptly report and investigate multiple incidents of alleged abuse and resident-to-resident altercations to the appropriate authorities. In one case, a resident with dementia and chronic pain reported being physically assaulted by a CNA, but the incident was not reported to law enforcement or the state agency, and the CNA continued working. In another case, two residents were involved in a physical altercation, but police were not notified. Additionally, an allegation of sexual abuse by a CNA was not reported within the required timeframe, and the accused CNA continued to work with residents. These failures resulted in noncompliance with federal requirements for reporting and investigating abuse.
The facility failed to assess two residents for safe self-administration of medications, leading to medications being left at their bedsides. One resident, cognitively intact, had medications left after dialysis without a safety assessment. Another resident, with intact cognition, had an inhaler and nasal spray left at the bedside without specific orders or care plan details. The facility's policy requires interdisciplinary team assessments and proper documentation, which were not conducted, resulting in a deficiency.
The facility failed to ensure proper food handling and sanitation practices, risking food-borne illness for residents. The ice machine had mold-like substances, and leftovers were not cooled properly. Unpasteurized eggs were used for a resident's meal, contrary to policy. The Dietary Manager and Registered Dietitian were unaware of these issues, indicating a lack of oversight.
Two LPNs failed to follow the facility's Enhanced Barrier Precautions policy during medication administration for two residents. One LPN did not wear a barrier gown while administering medication through a gastrostomy tube, and another did not wear a gown while accessing a PICC line. Both LPNs acknowledged the oversight, and the Director of Nursing confirmed these were high-risk activities requiring barrier gowns.
Improper Hair Restraints During Food Preparation
Penalty
Summary
Food was not prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. During observations, the Dietary Manager (DM)-C, Dietary Aide (DA)-D, and DA-E were seen preparing and handling food without wearing hair restraints that covered facial hair, and DA-E was also observed wearing a hat that did not fully restrain hair. The Wisconsin Food Code was cited as requiring food employees to wear hair restraints such as hair coverings or nets and beard restraints designed and worn to keep hair from contacting exposed food. Surveyors observed DM-C handling food in the main kitchen without a beard restraint on multiple occasions, including during the initial tour and again later the same morning. DM-C, DA-D, and DA-E were also observed preparing and handling food without proper facial hair restraints, and DA-E was repeatedly observed wearing a hat that did not fully restrain hair. When the concern was shared with DM-C, DM-C stated that facial hair could be less than a quarter inch in length without wearing a beard restraint and said proper hair and beard restraints would be obtained right away. The NHA and DON were informed of the findings, and no additional information was provided as to why food was not prepared, distributed, and served in accordance with professional standards.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility did not ensure that it submitted accurate mandatory staffing information to CMS based on payroll and other verifiable and auditable data in a uniform electronic format for Payroll Based Journal Quarter 1 (October 1 through December 31, 2025). Survey review of the CMS Electronic Staffing Data Submission Payroll-Based Journal policy manual confirmed that staffing and census data must be timely and accurate, and that direct care staffing information, including agency and contract staff, must be submitted based on payroll and other verifiable data. Survey review of the facility’s PBJ Staffing Data Report for Fiscal Year 2026 showed excessively low weekend staffing for the quarter. However, review of weekend schedules from October through December 2025 showed licensed nurses and CNAs present on each shift for each unit, with numerous call-ins that were filled by facility staff or agency staff. The Scheduler stated staffing totals depended on census, that minimum staffing requirements were met or exceeded, and that agency shifts were removed when facility staff picked them up. The NHA and staff interviewed denied low weekend staffing, and CNA and LPN staff stated there was enough nursing staff and no concerns with staffing levels. Despite these records and interviews, the facility’s PBJ submission did not reflect the staffing shown on the schedules.
Expired and Loose Medications Found in Medication Carts
Penalty
Summary
Drugs used in the facility were not labeled in accordance with currently accepted professional principles. During observation of medication carts on the MESA unit, the surveyor found expired stock medications in the cart, including Vitamin B and Thiamin with expiration dates of 4/2026, Cetirizine with an unreadable expiration date and no open date, and Non-aspirin and Senna S with no expiration dates. The LPN stated that if a medication does not have an expiration date, the open date is placed on it and it is discarded 30 days later, and the Unit Manager stated the medications would be tossed and replaced. The surveyor also observed loose medication pills in two other medication carts. In the short hall medication cart, 58 loose pills were found in the drawers, and the RN disposed of them in the drug buster container. In the Garden unit medication cart, 5 loose medications and one bottle of liquid pain relief with an expiration date of 4/2026 were observed. The facility policy titled Medication Storage, with an implement date of 3/2026, did not document any policies regarding expired medications. The DON stated nurses usually review medications on the carts when residents discharge and monthly for expired medications, and said the expectation for loose pills in the medication cart was not known.
Missed and Undocumented Tube Feedings
Penalty
Summary
The facility did not ensure that a resident with a feeding tube received enteral nutrition as ordered and did not document missed or refused tube feedings. The resident had diagnoses including gastrostomy and dysphagia, and the annual MDS documented severe cognitive impairment with a feeding tube in place. The resident had an order for Osmolite 1.5 CAL via pump at 69 ml per hour for 12 hours overnight, with 150 ml flushes every 4 hours, to provide supplemental nutrition because the resident also ate a puree diet with thickened liquids and sometimes consumed only 25-50% of meals. Survey observations on multiple days showed the tube feeding bottle and flush bag hanging in the resident’s room while the resident was not present, with the feeding not running and the bottle appearing nearly full. On one day, the bottle was dated the prior evening and was almost full; on another day, the bottle was dated the prior evening and had about 900 to 1000 ml remaining. The surveyor could not locate documentation in the electronic record showing that the resident did not receive the ordered amount or explaining why the feeding remained largely unused. When questioned, an LPN stated the resident had been taken off the tube feeding early because the resident was pulling at the tube and that no notifications were made. The surveyor also found no documentation that the resident was disconnected before the ordered end time, that the physician was notified, or that the resident refused the feedings. Later documentation stated the NP was notified that the resident had been disconnected around 3 AM due to refusing the tube feed and therefore did not complete the feeding as ordered, but the surveyor’s observations and record review showed the resident had not received the full ordered nutrition and that the missed feedings were not documented at the time they occurred.
Failure to Develop Trauma-Informed Care Plans for Residents with PTSD
Penalty
Summary
The facility did not ensure trauma informed care was provided for 3 of 3 residents reviewed with diagnoses of PTSD. R7, R12, and R91 were admitted with PTSD, but the facility did not develop person-centered care plans identifying trauma triggers, individualized interventions, or monitoring related to their PTSD. The facility policy stated that trauma informed care should include identifying triggers, developing individualized interventions to decrease exposure to triggers or lessen their effects, and evaluating whether interventions were effective, with resident or representative involvement as appropriate. For R7, the record showed diagnoses including PTSD, depression, and schizoaffective disorder, with an activated POA and a BIMS score of 8 indicating moderate cognitive impairment. The trauma assessments documented that R7 initially reported no traumatic events, then later disclosed that a girlfriend was killed long ago. The social services assessment also documented no traumatic events and no known triggers. Survey review found no care plan specific to PTSD, no identified triggers, and no interventions to decrease exposure to triggers or mitigate their effects. Staff interviews confirmed that the facility did not really talk to nursing about R7’s PTSD or triggers, and that because the event occurred long ago, it was not added to the care plan. For R91, the record showed diagnoses including PTSD, traumatic brain injury, anxiety, and psychotic disorder, with intact cognition on the MDS. Trauma assessments documented multiple past traumatic events, including floods, hurricanes, being hit by a car, abusive husbands, assaults, homelessness, and deaths by overdose and suicide. The care plan addressed neurological status, anxiety, and behavior problems, including hallucinations, agitation, and allegations against peers, but survey review found no trauma informed care plan relating to PTSD or triggers. Staff stated that trauma assessments were completed annually or as needed, but if the trauma was in the past it was not care planned, and that only recent events or current symptoms would be added to the care plan. For R12, the record showed diagnoses including PTSD and depression, with a BIMS score of 11 indicating intact cognition. Trauma assessments documented multiple prior traumatic experiences, including car accidents, a fall from a jack, exposure to toxic substances and combat during Desert Storm, a scuffle, and a family suicide. The depression care plan addressed medications, psych consults, activities, and monitoring for depressive symptoms and risk of harm, but survey review found no trauma informed care plan relating to PTSD or triggers. Facility staff stated that trauma assessments were completed yearly or as needed, but past trauma was not care planned unless there was a recent event or current behavior related to PTSD.
Failure to Investigate and Protect Residents Following Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate two out of four allegations of abuse involving residents and did not take immediate steps to prevent further potential abuse while investigations were in progress. In one instance, a resident with multiple diagnoses, including dementia and chronic pain, reported being physically assaulted by a CNA in the kitchen area, resulting in pain and fear. Despite the resident's report and corroborating witness statements, the incident was not promptly investigated, and the accused CNA continued to work 46 shifts after the alleged event, leaving the resident and others unprotected from further potential abuse. The facility's Director of Nursing did not initially consider the incident as abuse and failed to initiate an investigation or report the event, even after being informed by staff and the resident. In another case, a resident with hemiplegia, cognitive communication deficits, and a history of behavioral care planning alleged inappropriate physical contact by a CNA during personal care. The resident reported the incident to the unit manager via voicemail but did not receive a response. The facility's investigation file showed conflicting statements from staff, and the resident was not directly asked about inappropriate touching during the investigation. The accused CNA continued to work with residents for nearly two weeks after the allegation was known to the facility. The investigation was not thorough, and the incident was not reported to the state agency as required. Both cases demonstrate that the facility did not follow its own abuse, neglect, and exploitation policy, which requires immediate investigation and protection of residents from further harm during the investigation process. The lack of timely and thorough investigations, as well as the failure to remove accused staff from resident care during the investigation, resulted in residents not being safeguarded from additional potential abuse. These failures led to a finding of Immediate Jeopardy, as there was a reasonable likelihood for serious harm to residents.
Removal Plan
- Interview resident to verify any adverse outcomes are present.
- Interview resident to determine preference for remaining at the facility and referrals for other living arrangements.
- Initiate a thorough investigation by the Director of Nursing, Administrator, and Regional Nurse, including interviews with all staff with knowledge of the incident.
- Interview residents who could have potentially witnessed the incident.
- Conduct in-service education program on investigations and reporting, including review of abuse policies, reporting requirements, and staff responsibilities.
- Initiate random audits of residents and staff to ensure incidents are identified, properly investigated, and reported.
- Review grievances at the Clinical Stand-up meeting for any potential investigations.
- Monitor compliance at the QAPI meeting until consistent substantial compliance is met.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
A deficiency occurred when a resident was not protected from physical and verbal abuse by a Certified Nursing Assistant (CNA). The resident, who had a history of chronic obstructive pulmonary disease, dementia, anxiety, and chronic pain, reported being attacked by the CNA in the doorway of the kitchen, resulting in pain to the left shoulder, left rib, and left knee. The incident led to the resident feeling fearful and unsafe within the facility. Witness accounts from dietary staff and other residents confirmed that the CNA had a physical altercation with the resident, including grabbing the resident by the forearm, pushing a cart away, and ultimately pushing the resident, causing the resident to fall into a door. The resident subsequently required medical evaluation and an invasive injection for left knee pain attributed to the incident. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and protection of residents from harm, as well as prompt reporting of alleged violations to appropriate authorities. However, the Director of Nursing (DON) did not initiate an investigation or report the incident when it was first brought to their attention. The DON treated the event as a dispute between staff members and did not recognize or address the resident's allegations of being grabbed or pushed. The incident was not reported to Adult Protective Services (APS) or other required agencies in a timely manner, and the facility failed to ensure the resident's safety during and after the event. Further review revealed that the resident's medical records documented an increase in left knee pain following the incident, with the resident reporting to their orthopedic doctor that they had been forcibly pressed into a wall, resulting in a flare of arthritis and significant pain. The facility did not receive or review the after-visit summary from the resident's doctor until over a month after the appointment, and the information was not provided to nursing staff for follow-up. Additionally, the Social Services Director was unaware of the abuse allegation, and there was a lack of communication and coordination among facility staff regarding the incident and the resident's ongoing complaints.
Failure to Provide Required Assistive Devices and Supervision Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident assessed as needing bilateral enabler bars for bed mobility and positioning did not have both enabler bars in place as indicated by the admission assessment and care plan. The resident was admitted with multiple diagnoses, including repeated falls, cognitive impairment, and total dependence for toileting hygiene, placing them at increased risk for falls. The initial assessment and care plan specified the need for enabler bars on both sides of the bed, and informed consent was obtained for their use. However, only the left enabler bar was installed, and the care plan was later revised to reflect the single enabler bar without a documented reassessment or rationale for the change. On the day of the incident, a CNA was providing care to the resident and rolled the resident away from themselves, contrary to proper technique, resulting in the resident continuing to roll and falling out of bed. The resident sustained a right hip fracture that required surgical intervention. Interviews with staff confirmed that only one enabler bar was present at the time of the fall, and that the CNA had not received education on proper turning technique until after the incident. The facility's policies required appropriate assistive devices and supervision to prevent accidents, but these were not followed in this case. Further review revealed inconsistencies in documentation and care planning. The care plan was revised to match what was physically in place rather than being driven by the resident's assessed needs. There was no evidence that less restrictive alternatives were attempted before the removal of the right enabler bar, and the consent forms did not specify the number of enabler bars. Additionally, assessments and documentation related to side rail use were incomplete or not properly filed in the medical record. These actions and omissions resulted in the resident not receiving adequate supervision and assistive devices to prevent accidents, directly leading to the fall and injury.
Failure to Timely Report and Investigate Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to report several incidents of alleged abuse, neglect, or theft to the state survey agency and/or law enforcement within the required timeframes, as mandated by their own policies and federal regulations. In one case, a resident with multiple medical conditions, including dementia and chronic pain, reported being physically assaulted by a CNA in the dining area. Despite the resident expressing pain and fear following the incident, and the event being witnessed by staff, the facility did not notify law enforcement or the state agency in a timely manner. The accused CNA continued to work for approximately 46 shifts after the incident, and the facility did not initiate a thorough investigation or safeguard the resident and others from potential further abuse. The incident was only reported to authorities after external parties, such as the resident's physician and Adult Protective Services, became involved. Another incident involved a physical altercation between two cognitively intact residents, where one resident threw water and the other retaliated by throwing a fan, resulting in physical contact. Although the incident was reported to the state agency, there was no documentation or evidence that law enforcement was notified, as required by facility policy. The administrator acknowledged that police notification was not documented and could not provide a reason for this omission. A third incident concerned allegations of sexual abuse made by a resident against a CNA. The resident reported that the CNA inappropriately touched her during personal care, and although the facility initiated an internal investigation, the allegation was not reported to the state agency or law enforcement within the required two-hour timeframe. The accused CNA continued to work with residents for several days after the allegation was made. The investigation was incomplete, with conflicting statements and a lack of direct questioning regarding the alleged abuse. The facility's failure to promptly report and thoroughly investigate these incidents resulted in noncompliance with federal requirements for the protection of residents from abuse, neglect, and exploitation.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents, R11 and R45, for the safe self-administration of medications, leading to medications being left at their bedsides. R11, who was cognitively intact with a BIMS score of 13 out of 15, was observed with a plastic cup of medications left by staff after returning from dialysis. The facility's policy requires an interdisciplinary team assessment for self-administration, but R11's care plan and EMR lacked evidence of such an assessment. Interviews with staff, including an LPN and the DON, confirmed the absence of a safety assessment for R11's self-administration of medications. R45, with a BIMS score of 15 out of 15, was observed with medications, including an inhaler and nasal spray, left at her bedside. Although R45's care plan mentioned that medications could be left at the bedside, it lacked specific details about which medications and for how long. The facility's policy requires quarterly assessments for self-administration, but R45's last assessment was dated nearly two years prior. Interviews with staff, including an LPN and the DON, revealed a lack of clarity and documentation regarding R45's self-administration of medications, with no specific orders or care plan details. The facility's policy on self-administration of medications emphasizes the need for an interdisciplinary team assessment and proper documentation in the care plan. However, both R11 and R45 were not assessed according to this policy, resulting in medications being left at their bedsides without proper authorization or documentation. The DON acknowledged the oversight in assessments and care planning, highlighting a gap in adherence to the facility's policy and procedures for medication self-administration.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food handling and sanitation practices in its kitchen, which had the potential to cause food-borne illness affecting 32 of 33 residents. The ice machine in the kitchen was observed to have a mold-like substance on its interior, including dark spots and a light-yellow shiny substance. The Dietary Manager (DM) acknowledged the presence of the mold-like substance and admitted that the ice machine had not been cleaned by the dietary department since he started his employment one and a half years ago. The Administrator was made aware of the issue but only provided an invoice from an outside company that last cleaned the ice machine over a year ago. The facility also failed to properly cool leftovers, as observed with a pan of scrambled eggs from breakfast that was not cooled to the required temperature. The DM admitted that the leftover eggs were not cooled down properly and were disposed of after being found at 46 degrees Fahrenheit. The DM was unaware of the rule to cool food down to 41 degrees Fahrenheit within six hours, indicating a lack of adherence to the facility's policy on cooling hazardous foods. Additionally, the facility did not use pasteurized eggs for over easy eggs served to a resident, R55, who had intact cognition and a medical history including type 2 diabetes mellitus and hypertension. The DM confirmed that unpasteurized shelled eggs were used, which were past their best-by date, and was unaware of the requirement to use pasteurized eggs for such preparations. The Registered Dietitian (RD) was not aware of the sanitation issues or the use of unpasteurized eggs until after the incidents occurred, highlighting a lack of oversight and communication within the facility's dietary department.
Failure to Follow Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The facility failed to ensure that two Licensed Practical Nurses (LPNs) adhered to the Enhanced Barrier Precautions (EBP) policy during medication administration for two residents. The policy, revised in October 2024, required the use of barrier gowns during high-contact resident care activities, such as accessing feeding tubes and PICC lines. However, during observations, LPN3 did not wear a barrier gown while administering medication through a gastrostomy tube for one resident, despite the presence of an EBP sign and supplies. Similarly, LPN5 did not wear a barrier gown while accessing a PICC line for another resident. Interviews with the LPNs revealed a misunderstanding or disregard for the necessity of wearing barrier gowns during these procedures. LPN3 believed there was no risk of infectious transmission, while LPN5 did not consider it necessary since only the PICC line was accessed. Both LPNs acknowledged that they should have followed the policy, as confirmed by the Director of Nursing, who stated that the procedures were indeed high-risk activities according to the facility's EBP policy.
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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.
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Nursing homes near Pleasant Prairie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avina On 32nd | 4.4 mi | ★★★★★ | 6 | 0 |
| Brookside Care Center | 4.9 mi | ★★★★★ | 0 | 0 |
| Avina Of Kenosha | 5.1 mi | ★★★★★ | 2 | 0 |
| Clairidge House | 5.4 mi | ★★★★★ | 28 | 0 |
| Sheridan Health And Rehabilitation Center | 5.5 mi | ★★★★★ | 33 | 0 |
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