Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Maple Grove Llc during CMS and state inspections, most recent first.
Food was not maintained in a safe and sanitary manner. A scoop was left in a flour bin, bacon and pie crusts were uncovered and unlabeled in the walk-in refrigerator, a staff member with facial hair was not wearing a beard restraint, and food brought in by a family member was found unlabeled and undated in a hallway refrigerator. The DM acknowledged the issues and stated the items should have been covered, labeled, dated, and properly restrained.
The facility failed to keep call lights within reach for multiple residents and failed to provide needed grooming assistance for a resident who required help with ADLs. Residents were observed in bed or in a wheelchair without accessible call lights, and one resident with dementia and neurocognitive disorder with lewy bodies had long facial hair despite needing staff assistance for shaving. Staff interviews confirmed the call lights were not properly accessible and that the resident needed help with personal hygiene.
Medications Left at Bedside Without Self-Administration Assessment: A resident with a BIMS of 15 and diagnoses including polyneuropathy and vitreous degeneration had medications left in a cup at the bedside on two observations. The resident's assessment stated she did not desire to self-administer medications, and there was no physician order or care plan documentation for self-administration. An MT said she left the medications for the resident to take, while an RN said the resident was supposed to be watched but preferred to take meds on her own.
A resident with multiple orthopedic and neurologic diagnoses and a BIMS of 13 voiced frustration that therapy was not scheduled at specific times and said it caused him to wait around all day and risk missing appointments. Staff acknowledged that residents commonly complained about therapy timing, but the concern was not documented as a grievance, investigated, tracked, or followed up through the facility's grievance process, despite the policy requiring verbal complaints to be recorded and resolved.
A resident admitted with major depressive disorder had a PASARR Level I screen indicating suspected serious mental illness, but the medical record did not include a PASARR Level II screen. The SW confirmed she was responsible for obtaining PASARR screenings and stated the resident should have had a Level II screen completed but did not.
Failure to provide ongoing assessment after a fall: A resident with stroke, difficulty walking, and moderate cognitive impairment fell in the bathroom and had immediate right-sided pain rated 10/10. Although a post-fall assessment was completed, staff did not complete ongoing nursing assessments or notify the primary provider when the resident later reported increased pain at 8/10, and the resident was not sent to the ER until the next evening by ambulance.
Failure to Measure and Offload a Right Heel Pressure Injury: A resident with DM, PVD, and a history of skin breakdown developed a right heel PI that was identified as a deep tissue injury and later progressed to stage 2 and then unstageable. Staff did not obtain wound measurements for about two weeks after discovery, several skin reviews lacked wound details, and surveyors observed the resident without ordered offloading boots in the recliner and wheelchair even though staff said the boots were to be worn at all times.
A resident with severe cognitive impairment and a history of aggressive, threatening dining behaviors was supposed to use plastic silverware at meals per the care plan. During observation, staff found him with metal fork and knife after he reportedly said he would stick them in his throat, and he was later repeatedly seen eating breakfast with metal utensils despite staff knowing the plastic silverware instruction.
A resident with a suprapubic indwelling catheter, bladder dysfunction, and a recent UTI was observed in the dining room with the catheter drainage bag hooked to the wheelchair and resting in direct contact with the floor on more than one occasion. Staff, including a CNA, an LPN, and the DON, acknowledged the bag should not have been on the floor, and the facility policy and CDC guidance cited in the report state the drainage bag should be kept below the bladder and not rested on the floor.
A resident with depression, anxiety, and skin-picking disorder disclosed a past sexual assault, but the trauma assessment was incomplete and the care plan lacked trauma-specific focus, goals, or interventions. The SW acknowledged the resident’s trauma history and stated a new assessment and care plan update should have been completed but were not.
A resident receiving hospice care had missing and outdated hospice documentation, and staff gave conflicting accounts of where the hospice plan of care was kept. Surveyors found only hospice contact sheets in a binder, while the paper chart contained a hospice plan that had just been printed and still listed the resident as living at home with home health services. The DON said hospice notes were expected after each visit and that floor nurses and unit managers were responsible for keeping the hospice plan updated, but the facility could not produce the resident’s hospice binder or visit notes.
A resident with Parkinson’s disease experienced repeated late administration of scheduled carbidopa-levodopa doses, and one dose was given so late that it resulted in a duplicate dose the next morning. The resident stated the Parkinson’s meds were not given on time, while an LPN and the DON were unsure whether the timing issues constituted a med error or what risks were associated with delayed or duplicated dosing.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not maintained safely and supervision was lacking, but does not specify further details.
Three residents at the facility did not receive fall interventions as outlined in their care plans, nor adequate supervision to prevent accidents. One resident with a history of frequent falls, including a head injury, was not provided increased supervision despite repeated incidents in similar settings. Another resident was observed ambulating without her walker and lacked the required reminder signage. A third resident with wandering and behavioral issues was not given additional supervision to prevent entry into other residents' rooms, increasing the risk of altercations.
Staff did not consistently follow professional standards for food service safety, as a dietary aide failed to allow the thermometer to dry after sanitizing before checking food temperatures and did not check all required food items, including ground and pureed foods. The dietary manager confirmed that all food temperatures should be taken and that the thermometer should be dry before use, but these practices were not followed.
Several residents reported that a cognitively impaired resident repeatedly entered their rooms uninvited, sometimes sitting on their beds or in their wheelchairs, and in one instance, causing pain by sitting on a recent surgical site. Staff were aware of the ongoing intrusions and attempted redirection and other interventions, but these were not effective in preventing the behavior. The facility did not implement measures to stop the unwanted entries, resulting in a failure to protect residents' dignity and privacy.
Surveyors found that multiple medications, including PRN and as-needed drugs, were expired or lacked proper labeling such as open dates on a medication cart. An LPN confirmed that medications should be checked for expiration before administration and that expired drugs should be discarded. The DON reported that the pharmacist is responsible for auditing medication carts and rooms, but checks may only occur monthly and require advance scheduling. These findings indicate that the facility did not consistently follow its own policy for medication storage and labeling.
A resident with multiple medical conditions, including arthritis and macular degeneration, was observed with medications left at the bedside for self-administration without a completed assessment or physician order. Staff left medications based on the resident's preference, but documentation and interviews revealed the resident could not identify her medications and had recently needed assistance. The required assessment process was not followed prior to allowing self-administration.
A resident raised concerns about staff using personal cell phones during work hours, but the facility did not document or investigate the grievance as required by policy. Surveyors observed multiple LPNs using cell phones for personal matters, and the resident reported no follow-up on her complaint. The grievance was not entered into the log, and the required investigation and resolution steps were not completed.
A resident with moderate cognitive impairment and mobility needs was repeatedly observed seated in a Broda chair with the brakes engaged, preventing self-movement. The brakes were positioned out of the resident's reach, and staff interviews confirmed that this restricted the resident's freedom of movement, meeting the facility's definition of a physical restraint. The care plan did not indicate a medical need for this restraint.
Three residents did not have their individual needs and preferences addressed in their care plans, including one resident whose care plan for interpreter services was not followed, and two residents whose religious practices as Muslims were not included in their care plans. Staff were unaware of the residents' language or religious requirements, and facility policy requiring person-centered, culturally competent care planning was not met.
A resident with moderate cognitive impairment and multiple medical conditions expressed a desire to move to assisted living, but the care plan continued to reflect a long-term stay in the facility. Although the social worker was aware of the resident's goal and began working on placement, the care plan was not updated to match the resident's current wishes, as confirmed by both the SW and DON.
Two residents who are practicing Muslims did not have their religious and cultural needs accommodated, as their care plans failed to reflect their preferences for prayer and cleanliness. Both residents reported being unable to practice their faith as required, and staff interviews revealed a lack of awareness or incorrect information about their religious needs. Facility policies requiring person-centered care and respect for resident choices were not followed.
Two residents who were dependent on staff for ADL support did not receive timely assistance with personal hygiene, grooming, and toileting as required by their care plans. One resident was repeatedly observed with unkempt hair and long whiskers, while another was left in urine-soaked clothing for extended periods. Staff interviews and documentation revealed inconsistent care and a lack of adherence to facility policies, resulting in compromised dignity and unmet care needs.
A resident with a stage 4 pressure injury did not receive care as ordered by the physician, including required repositioning and time limits in a wheelchair. Staff were unaware of the specific repositioning schedule, and the care plan and care card did not reflect the individualized orders. The resident was observed remaining in her wheelchair beyond the allowed time without repositioning, and the facility could not provide a pressure injury care policy when requested.
A resident with chronic pain and multiple medical conditions experienced ongoing pain during transfers with an EZ stand lift, despite repeatedly expressing discomfort and requesting alternative methods. Facility staff and leadership were aware of the resident's pain, but did not reassess her pain management plan, update her care plan, or implement new transfer approaches, resulting in continued daily pain.
A resident with a history of falls and cognitive impairment experienced multiple falls from a lift chair, including one resulting in a femur fracture, after the facility failed to assess the resident's ability to safely use the chair and did not provide adequate supervision or staff education on fall prevention.
A resident with a physician-ordered Level 7: Easy to Chew diet was regularly provided with snacks such as cheese crackers, Cheetos, and potato chips by staff and family, despite these items not being compliant with her prescribed diet. Staff, including a speech therapist, allowed these exceptions for quality of life reasons but did not document them or update the care plan. The registered dietician and DON confirmed that these exceptions were not communicated or recorded in the resident's medical record.
A resident's medical record contained conflicting care plan entries regarding their ability to self-administer medication, with some documentation allowing self-administration and other entries prohibiting it and requiring observation. Staff interviews revealed confusion about the resident's self-medication status, and no physician order authorizing self-administration was found in the EMR. The DON acknowledged the conflicting information in the care plan.
The facility failed to properly install and test bed rails for four residents, leading to potential safety risks. Bed rails were installed without conducting necessary tests to ensure proper installation and reduce entrapment risks. The Maintenance Supervisor admitted that a new employee, untrained in using the measurement device, was installing bed rails, and several installations had not been tested. The Nursing Home Administrator confirmed that testing should occur upon installation, but the facility lacked documentation of actual installation dates.
A resident, who required two-person assistance for bed mobility, fell out of bed when a CNA attempted to assist her alone, contrary to her care plan. The resident became wedged between the bed and the wall, highlighting the facility's failure to ensure staff were trained and aware of care plans. The Nursing Home Administrator was unaware of the frequent single-staff assistance, and several staff members had not received necessary education or competency testing.
A resident with quadriplegia was burned by hot coffee served at 185°F in bed, as the facility lacked safety protocols for hot liquids. The resident attempted to switch the coffee cup from his left to his weaker right hand, resulting in a spill and burns. The facility did not assess the safety of serving hot liquids to residents, nor did it monitor beverage temperatures, leading to this incident.
A resident receiving psychotropic and antipsychotic medications was not adequately monitored for behavior and side effects, leading to unnecessary medication use. The facility failed to document quantitative behavior tracking, using inappropriate charting methods. Staff interviews indicated the resident's behaviors were not harmful, contradicting the need for antipsychotic medication.
A resident with dysphagia and a history of aspiration events experienced two choking incidents due to inadequate supervision and failure to adhere to dietary restrictions. The resident was served inappropriate food items, leading to hospitalization. Staff interviews revealed a lack of clarity and responsibility in verifying meal tickets and ensuring correct diets, contributing to the deficiency.
The facility did not conduct annual performance reviews for three CNAs, as required by its policy. The last evaluations for these CNAs were conducted in 2022, despite their long-term employment. The facility's leadership indicated that evaluations were conducted every three years, contrary to the policy's annual requirement.
A resident with Vitamin B Deficiency did not receive their prescribed Vitamin B Complex-C medication due to unavailability, and the facility failed to notify the physician as required by policy. Despite the ADON being informed of the medication error, the physician was not notified, leading to a deficiency identified by surveyors.
A resident with cognitive intactness and multiple medical conditions reported a grievance about a CNA leaving her unable to eat her meal. The charge nurse was informed and reported the incident to the DON, but the grievance was not followed up on or formally documented, violating the facility's grievance policy.
A facility failed to report an alleged verbal abuse incident involving a resident to the State Agency. The resident's daughter reported that a CNA yelled at her mother, but the NHA closed the grievance due to lack of additional information from the daughter. The NHA acknowledged that the incident should have been reported as verbal abuse.
The facility failed to thoroughly investigate abuse allegations involving two residents. One resident was neglected during the night shift, and the investigation lacked interviews with day shift staff and other residents. Another resident's verbal abuse allegation was inadequately investigated, with no follow-up for non-verbal residents. The facility's policy for timely and thorough investigations was not followed.
A resident at risk for pressure injuries developed an infected pressure injury on her left foot bunion due to the facility's failure to implement timely interventions and assess contributing factors such as footwear. Despite being cognitively intact and having a care plan noting skin integrity risks, the facility did not conduct daily diabetic foot checks or address the cause of the initial redness, leading to the injury's progression and infection.
A facility failed to provide daily diabetic foot care for a resident with Type 2 Diabetes Mellitus, as required by their policy. The resident lacked a physician order for daily foot checks, resulting in the task not appearing on the TAR. Nursing staff only performed checks if listed on the TAR, and the DON confirmed checks were done weekly instead of daily, contrary to policy.
A resident with neurocognitive disorder and muscle weakness, who required 1:1 supervision due to wandering, was left unattended by a CNA, resulting in a fall. The resident's care plan lacked details on the required supervision, and the CNA acknowledged leaving the resident without ensuring a replacement. The RN and DON confirmed the need for continuous supervision, indicating a lapse in maintaining safety protocols.
A resident with Vitamin B Deficiency, Multiple Sclerosis, and Muscle Weakness did not receive their prescribed Vitamin B Complex-C Oral Capsule due to a failure in the facility's pharmaceutical services. Despite multiple attempts by staff to resolve the issue with the pharmacy, the medication was unavailable for several weeks, indicating a breakdown in communication and procedure.
The facility failed to establish an effective infection prevention and control program, affecting all 106 residents. Issues included incomplete daily infection control surveillance for staff, inaccurate infection control line lists, and improper calculation of infection control rates. Additionally, a CNA did not disinfect a resident's bedside table after placing a urinal on it, posing a risk of cross-contamination.
The facility failed to complete PASARR Level II screens for four residents with serious mental illnesses or intellectual disabilities who stayed longer than 30 days, despite initial exemptions. This oversight was due to a change in responsibility for completing assessments and a gap in social worker staffing.
The facility failed to provide an ongoing program of activities to meet the interests and well-being of residents, particularly on weekends and evenings. Seven residents voiced concerns about the lack of activities, especially missing church services on Sundays. The activity staff and Nursing Home Administrator acknowledged the issue but had not implemented changes to address the deficiency.
The facility failed to ensure proper storage and labeling of medications, with surveyors observing undated, open stock medications, improperly stored refrigerated medications, and co-mingled administration routes in medication carts. Additionally, some medications were found without labels or resident identification, and expired medications were not discarded as per manufacturer recommendations.
The facility failed to follow its antibiotic stewardship program, leading to inappropriate and prolonged antibiotic use for several residents. Staff did not always document or clarify the necessity and duration of antibiotics, resulting in unnecessary treatments.
A resident with dementia, requiring moderate assistance for eating, was observed with a plate of food that remained in front of her for 34 minutes before a CNA began feeding her. The food temperature was found to be 113 degrees Fahrenheit, and the facility staff replaced the food.
The facility failed to report alleged abuse and a missing narcotic pain patch to the appropriate authorities and did not suspend the staff member involved in the abuse allegation. The facility did not follow its own policies and procedures, compromising resident safety during investigations.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. During an initial kitchen walkthrough on 6/29/26, the surveyor observed a scoop left in the flour bin and observed bacon and pie crusts uncovered in the walk-in refrigerator with no label or date. The Dietary Manager acknowledged that the scoop should not have been left in the bin and stated that food items should be covered, labeled, and dated. On 6/30/26, the surveyor observed a staff member with facial hair not wearing a beard restraint. Later that day, the surveyor observed items in the 100-hallway refrigerator that were not labeled and dated and were identified by the Dietary Manager as fruit brought in by a family member. The Dietary Manager stated these items should have been labeled and dated and indicated staff with facial hair should wear a beard restraint. On 7/2/26, the Nursing Home Administrator indicated understanding of these concerns.
Call Lights Not Kept Within Reach and ADL Grooming Not Provided
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene, and it also failed to keep call lights within reach for multiple residents. The deficiency involved 5 of 21 residents reviewed for accommodation of needs out of a sample of 25, including residents observed in bed or in a wheelchair without access to a call light and one resident with long facial hair who had not been shaved despite needing assistance. R15 was observed in bed with a call pendant in the windowsill and no call light plugged into the wall, and RN D stated the pendant should not have been there and that R15 could not reach it. R41 was observed in bed with the call light clipped to the cord hanging behind the bed and out of reach, with CNA E stating R41 did not have a pendant and should have access to the call light. R111 was observed with the call light wrapped around the bed while sitting in a wheelchair and unable to reach it, and CNA CC placed the call light near the resident so it was accessible. R24, who had diagnoses including dementia and neurocognitive disorder with lewy bodies and a care plan calling for 1-assist with personal hygiene and oral care, was observed with long facial hair and stated a desire to be clean shaved. CNA BB stated R24 preferred to be clean shaved, could use an electric razor with staff assistance, and needed staff help for all ADLs, but also noted the razor cord was missing and that may be why R24 had not been shaved. R75 was overheard yelling for help and stated he waited a long time for his call light to be answered; staff found no call light or pendant near him until the Housekeeping Director brought one and placed it around his neck. The DON stated residents should always have access to a call light and that all residents should have access to a bracelet, necklace pendant, or wall call light.
Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that all residents were clinically appropriate to self-administer medications for one resident observed with medications at bedside. The resident had diagnoses including polyneuropathy and vitreous degeneration of unspecified eye, and the quarterly MDS showed a BIMS score of 15, indicating the resident was cognitively intact. However, the resident's Quarterly/Annual/Significant Change Assessment dated 5/27/26 stated that the resident did not desire to self-administer her own medications, and there was no physician order for self-administration in the MAR or information in the comprehensive care plan addressing self-administration. Surveyors observed two medications in a cup on the resident's bedside table on one occasion and all of the resident's morning medications in a cup on the bedside table on another occasion. The resident stated the nurse brought the medication in but she had not taken them yet. A medication tech stated she had left the medications for the resident to take and believed the resident was able to self-administer medications, while an RN stated the resident was supposed to be watched while taking medications but preferred to take them on her own. The DON confirmed that the facility's process required a self-administration assessment, a physician's order, and care plan documentation, and stated the resident should not have medications left at bedside.
Failure to Document and Resolve Resident Grievance About Therapy Scheduling
Penalty
Summary
The facility did not make prompt efforts to document, investigate, or resolve a resident grievance involving therapy scheduling. The resident involved, R121, was admitted with diagnoses including polyneuropathy, cervical disc disorder with myelopathy, spinal stenosis of the lumbar and cervical regions with neurogenic claudication, and osteoarthritis of both knees. His most recent MDS showed a BIMS score of 13 out of 15, indicating he was cognitively intact. His care plan identified that he was admitted following a hospital stay with a goal of returning home after short-term rehabilitation. During interview, R121 expressed frustration that therapy appointments were not scheduled at specific times and said this created chaos because he had to wait around all day and could miss therapy while trying to complete other activities. Surveyor review of the grievance log from 4/1/26 to 6/29/26 showed no grievances related to therapy scheduling. Staff interviews showed that residents commonly voiced concerns about not having set therapy times, but these concerns were handled informally rather than documented as grievances. The Rehab Director stated residents often complained about the lack of a set schedule, and the Physical Therapist said complaints were sometimes passed to the Rehab Director or written as preferences in notes, but she was unsure whether they were documented as grievances. The Director of Nursing stated she was not aware of residents' concerns about therapy scheduling, while the Social Worker acknowledged that residents had voiced concerns about wanting therapy at certain times and asked whether these concerns should have been logged as grievances. The Nursing Home Administrator stated he had heard something from the Rehab Director about therapy scheduling but believed it had been taken care of and did not look into it. The facility's grievance policy required verbal complaints to be recorded on a grievance form, forwarded to the Grievance Official, investigated, tracked to conclusion, and followed by a written decision, but those steps were not completed for R121's concern.
PASARR Level II Screen Not Completed
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one resident reviewed for PASARR screening. The resident was admitted with diagnoses including major depressive disorder and had a quarterly MDS assessment with a BIMS score of 15, indicating cognitive intactness. The resident’s PASARR Level I Screen Summary stated that the person had a major mental disorder and that the screening result was that the resident was suspected of having a serious mental illness, but the medical record did not include a PASARR Level II screen. During interview, the Social Worker stated she was responsible for obtaining PASARR screenings, confirmed the resident did not have a PASARR Level II screen, and stated the resident should have had one completed but did not.
Failure to Provide Ongoing Assessment After a Fall
Penalty
Summary
The facility did not ensure that R5 received treatment and care in accordance with professional standards of practice after a fall. R5 was admitted with diagnoses including stroke, difficulty walking, and unspecified fall, and the most recent MDS showed a BIMS score of 8, indicating moderate cognitive impairment. The care plan identified R5 as at risk for falls and with a history of falls. On 3/21/26 around 7:45 PM, R5 was found on the bathroom floor on knees with arms up on the grab bars beside the toilet, trying to get up. At a standing position, R5 was able to march both feet but had more difficulty on the right side, and immediately rated pain as 10/10 on the right side. The on-call MD was notified and gave orders to treat a skin tear on the left wrist, with further evaluation if R5 became unable to bear weight. The facility completed a post-fall assessment and head-to-toe checklist at the time of the fall and a follow-up post-fall document early the next morning, but survey review found no ongoing assessments or provider notification after R5 later reported increased pain. On 3/22/26 at 8:37 AM, documentation showed R5 stated pain was 8/10, and staff gave a PRN medication that was effective, but the facility did not notify the primary provider of the increased pain. Survey review also found no follow-up assessments until the evening of 3/22/26, when R5 went to the ER by ambulance. The DON stated nursing should provide ongoing monitoring and assessment after a fall and would expect staff to notify the primary physician if a resident is experiencing increased pain after a fall.
Failure to Measure and Offload a Right Heel Pressure Injury
Penalty
Summary
The facility failed to ensure appropriate pressure injury care and failed to prevent worsening of a resident’s right heel wound. The resident had diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease and peripheral vascular disease, and had a history of pressure injuries and skin blistering. The resident’s Braden score was 13 on 1/29/25, indicating moderate risk for pressure injury development. The care plan included interventions for skin integrity, including offloading boots to both feet when in bed and in the recliner at all times, weekly skin checks, and monitoring for skin changes. On 4/1/26, the nurse practitioner identified a wound on the right heel and documented it as a deep tissue pressure injury with surrounding dark tissue and sanguineous drainage. Orders were entered for offloading boots and wound care. However, the first wound measurements were not obtained until 4/14/26, about two weeks after the wound was discovered. The weekly skin reviews on 4/2/26 and 4/9/26 documented the wound as open, but did not include wound measurements or wound characteristics. Later wound assessments showed progression from a stage 2 wound with granulation tissue and moderate drainage to an unstageable wound with eschar covering most of the wound bed. Survey observations on 6/29/26 showed the resident in a recliner and later in a wheelchair without the ordered offloading boots in place; the boots were observed sitting in the windowsill next to the bed. Staff interviews confirmed that the boots were expected to be worn at all times, including in bed, the recliner, and the wheelchair. Staff also stated that wound measurements should be completed weekly, but acknowledged that measurements were not started until the wound was classified as a pressure injury on 4/14/26. The record also showed a missed skin assessment on 6/23/26 and several wound entries without descriptions of wound bed characteristics.
Failure to Follow Care Plan for Plastic Silverware
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices were provided to prevent accidents for a resident whose care plan directed that plastic silverware be used at meals. The resident had diagnoses including mild dementia with anxiety, bipolar disorder, personality disorder, impulse disorder, and anxiety disorder, and his most recent MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. He also had an activated HCPOA. During lunch observation, the resident was seen sitting alone in the dining room when a CNA removed his metal fork and knife after the resident reportedly told the CNA he was going to stick them in his throat. The CNA reported the incident to a med tech, who contacted the charge nurse and the unit LPN. The resident was then given a plastic spoon to finish his meal. The resident’s care plan specifically stated, “Plastic silverware to be used for meals,” and progress notes documented multiple prior behavioral incidents involving utensils, including threatening behavior with a fork, throwing utensils at other residents, and threatening staff with a glass of juice. Despite the care plan instruction and the resident’s history of aggressive and threatening behaviors during meals, the resident was repeatedly observed using metal silverware at breakfast on subsequent days. On one occasion, a CNA acknowledged the resident should have plastic silverware but did not remove the metal utensils until another CNA later switched them out. Interviews with staff showed awareness that the resident was supposed to have plastic silverware, but the intervention was not consistently followed during meals.
Catheter Bag Resting on Floor
Penalty
Summary
The facility did not ensure appropriate catheter care for a resident with a suprapubic indwelling catheter. The resident had diagnoses including neuromuscular dysfunction of the bladder, presence of urogenital implants, and retention of urine, and the physician ordered the suprapubic catheter to be changed every 4 weeks with urology evaluation every 6th catheter change. The resident’s care plan identified actual, at-risk, and potential complications related to suprapubic catheter use and included use of a dignity bag for the Foley when not in the room. The resident also had been treated for a UTI in 5/2026. Surveyors observed the resident eating lunch in the dining room with the catheter bag hooked on the bottom of the wheelchair and resting in direct contact with the floor. The same condition was observed again while the resident was eating breakfast in the dining room on a later date. Staff were notified each time, and a CNA, an LPN, and the DON acknowledged that the catheter bag should not have been touching the floor. The facility policy stated catheter drainage bags should be covered at all times while in use, and the CDC guidance cited in the report states the collecting bag should be kept below the bladder and not rested on the floor.
Incomplete trauma assessment and care plan for resident with disclosed sexual assault history
Penalty
Summary
The facility did not ensure trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and the resident’s experiences and preferences. For 1 of 3 residents reviewed for trauma-informed care, R102 disclosed a history of sexual assault, but the resident did not have a complete trauma assessment or a care plan addressing triggers, resident-specific approaches, or interventions. R102 was admitted with diagnoses including depression, anxiety, and skin-picking disorder, and had a BIMS score of 14, indicating cognitive intactness. R102’s Trauma Informed Care Assessment dated 6/8/26 contained multiple blank responses, including items related to physical assault, life-threatening illness or injury, severe human suffering, and other stressful events, and the PC-PTSD-5 screening questions were also left blank. On 6/30/26, R102 told the surveyor about a past sexual assault. The comprehensive care plan printed 7/1/26 did not include any trauma-specific focus, goals, or interventions. The Social Worker stated she had been told on 6/25/26 or 6/26/26 about the traumatic sexual incident from when R102 was a teenager, and acknowledged that a new trauma assessment and care plan update should have been completed but were not.
Missing and Outdated Hospice Plan of Care
Penalty
Summary
The facility did not ensure that hospice services met professional standards and principles for a resident receiving hospice care. The deficiency involved one resident, who was admitted to the facility with diagnoses including malignant neoplasm of connective and soft tissue of the right lower limb/hip, chronic ulcers of the right foot and lower leg, chronic pain, and pain in the right leg, and who was admitted to hospice with a primary hospice diagnosis of primary angiosarcoma of the right lower extremity. The resident’s comprehensive care plan included hospice-related interventions such as notifying hospice of changes in condition or medication changes and providing emotional support during decline. Surveyors interviewed multiple staff members about where the resident’s hospice care plan and hospice documentation were kept. A CNA stated hospice managed the resident’s wound and pain medications and said a care plan was located in the bathroom. An LPN stated the hospice care plan was in the PCC electronic record. The DON stated hospice notebooks were at the nurse’s station. However, when surveyors asked staff to locate the hospice binder, an LPN and an RN could not find it, and the RN stated hospice usually fills it out and brings it back to the nurse’s station, but it was not there at the time. Later, staff showed surveyors a binder containing only hospice contact information and no plan of care. The resident’s paper chart contained a hospice plan of care, but it had been printed that day and still reflected that the resident was living at home with home health services, which an MT acknowledged needed to be updated. The MT also stated hospice providers print their notes and include them in the paper chart, but she did not see evidence of those visit notes in the chart. The DON stated the facility gets hospice notes every time hospice visits and that floor nurses and unit managers are responsible for obtaining the notes and keeping the hospice care plan updated, but she also stated the resident’s binder was missing and described it as a fluke. The facility did not ensure collaboration and coordination with hospice for a complete plan of care for the resident receiving hospice services.
Late and Duplicate Administration of Parkinson’s Medication
Penalty
Summary
The facility did not ensure that one resident with Parkinson’s disease was free from significant medication errors when scheduled carbidopa-levodopa doses were not administered as ordered. The resident had diagnoses including Parkinson’s disease, Alzheimer’s disease, restless legs syndrome, major depressive disorder, and anxiety disorder, and was documented as cognitively intact with a BIMS score of 15 out of 15. During interview, the resident stated that Parkinson’s medications were not given on time and that doses were sometimes about an hour late. The physician’s order for carbidopa-levodopa ER 25-100 mg was for one tablet by mouth every six hours for Parkinson’s disease, with the MAR showing scheduled administration times of 5:00 AM, 11:00 AM, 5:00 PM, and 11:00 PM. Review of the medication administration audit reports showed multiple late administrations in December 2025 and June 2026, including doses given hours after the scheduled time. One documented event showed the 11:00 PM dose given at 5:05 AM the next day, resulting in a double dose at 5:05 AM on 12/02/25. During observation and interview, an LPN stated scheduled medications should be given within one hour before or after the scheduled time and was unsure whether a dose given at 2:00 PM for an 11:00 AM order would be a medication error or whether there were risks associated with late administration or two doses being given at the same time. The DON stated medications were administered late and was also unsure whether this was a medication error or whether there were risks associated with not administering carbidopa/levodopa as ordered.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Failure to Implement Fall Interventions and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that fall interventions were implemented according to the care plan and that residents received adequate supervision to prevent accidents, as evidenced by the experiences of three residents reviewed for falls and supervision. One resident, who was identified as a fall risk and had a history of 23 falls since admission, experienced repeated falls in similar locations and times, including a fall resulting in a head injury that required sutures. Despite the facility conducting a root cause analysis and collecting data on these incidents, there was no evidence that the interdisciplinary team comprehensively reviewed the data or considered increasing supervision for this resident. The care plan included multiple interventions, such as moving the resident closer to the nurse's station and providing increased monitoring, but these were not consistently or effectively implemented, particularly in the dining room where several falls occurred without increased supervision. Another resident, who was care planned to walk with a walker and have a sign in her room as a reminder, was observed on two separate occasions walking without her walker. Additionally, the required sign was not present in her room, indicating a failure to implement care plan interventions designed to reduce fall risk. This lack of adherence to the care plan placed the resident at increased risk for falls. A third resident, known to have wandering behaviors and a history of acting out toward staff and other residents, was not provided with increased supervision to prevent entry into other residents' rooms. This lack of supervision created a risk for potential resident-to-resident altercations. The facility's fall prevention policy required individualized assessment and implementation of interventions based on risk, but the observed failures in supervision and care plan implementation for these residents demonstrate noncompliance with the policy and regulatory requirements.
Failure to Follow Food Service Safety Standards During Meal Preparation
Penalty
Summary
Staff failed to follow professional standards for food service safety during meal preparation and service. During observation, a dietary aide was seen taking food temperatures at the steam table but did not allow the thermometer to dry after cleaning it with an alcohol wipe before placing it into the next food item. This practice was repeated for all foods being checked. Additionally, the dietary aide did not take the temperature of all food items, specifically omitting ground and pureed foods on the steam table. When questioned, the dietary aide stated that only certain foods deemed important were being checked for temperature. The facility's policy requires that temperatures for each food product and milk be measured and recorded at all meals, and that thermometers used for this purpose must be clean, sanitized, and dry before use. The dietary manager confirmed that all food temperatures should be taken at every meal and that the thermometer should be dry before being used in another food item. These observations and staff interviews demonstrate that the facility did not consistently store, prepare, distribute, and serve food in accordance with professional standards for food service safety, potentially affecting all residents.
Failure to Prevent Resident Intrusions Violates Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity by not preventing a resident with dementia from repeatedly entering other residents' rooms uninvited. Multiple residents, including those who were cognitively intact and those with varying levels of cognitive impairment, reported that this resident would enter their rooms, sit on their beds or in their wheelchairs, and in one case, sat on a resident's recently operated knee, causing pain and distress. Staff and residents confirmed that these intrusions were ongoing and that the affected residents did not want this behavior to continue. Observations and interviews revealed that staff were aware of the wandering behavior and its impact on other residents. Staff described redirecting the resident as the primary intervention, but acknowledged that these efforts were not always effective. Some staff reported that the resident could become combative when redirected and that interventions such as walking with the resident, offering activities, or using visual cues like STOP signs had limited or no success. Documentation showed that the resident continued to wander into rooms, including at night, and that staff sometimes had to take turns sitting with her to prevent further incidents. Despite being aware of the problem and receiving grievances from residents, the facility did not implement effective interventions to prevent the resident from entering others' rooms uninvited. The affected residents expressed discomfort, frustration, and, in one case, physical pain as a result of these intrusions. The facility's actions and inactions led to a failure to honor residents' rights to dignity, privacy, and self-determination as required by policy and regulation.
Expired and Unlabeled Medications Found on Medication Cart
Penalty
Summary
Surveyors identified that the facility failed to ensure drugs and biologicals were properly labeled and stored according to professional standards on one of three medication carts reviewed. During observation, several medications were found to be expired, including PRN Hydralazine, Chest Congestion Relief, ondansetron, stimulant laxative, and calcium antacid cards. Additionally, a nasal spray lacked an open date, and eye drops had an open date but were not properly monitored for expiration. These findings were confirmed during interviews with an LPN, who acknowledged that medications should be checked for expiration before administration and that expired medications should be discarded. The Director of Nursing stated that the process for removing expired medications involves the consultant pharmacist auditing the carts and medication rooms, with expired items being sent back to the pharmacy. However, the DON indicated uncertainty about the frequency of these checks, believing it to be monthly and requiring advance scheduling. The facility's own policy requires routine inspection for discontinued, defective, or deteriorated medications, but the observed deficiencies indicate this process was not consistently followed.
Failure to Assess Appropriateness for Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was clinically appropriate to self-administer medications, as required by policy. A resident with diagnoses including polyosteoarthritis, type 2 diabetes mellitus, muscle weakness, and unspecified macular degeneration was observed with a cup of medications left on her bedside table for independent administration. There was no completed assessment or physician order in place at the time of the observation to support that the resident was safe to self-administer medications. The facility's policy requires an interdisciplinary assessment of the resident's physical and cognitive abilities, as well as a physician order, before allowing self-administration of medications. Record review showed that the resident had a BIMS score indicating cognitive intactness but required substantial to maximal assistance with activities of daily living and had limited range of motion in both upper extremities. The assessment tool used by the facility indicated that the resident could not name her medications, dosages, or reasons for use, and the assessment and order for self-administration were only completed after the surveyor's observation. Interviews with staff revealed that medications were left at the bedside based on the resident's preference to have them available before breakfast, but staff acknowledged that the resident did not meet all criteria for self-administration and that the required assessment process had not been followed prior to the incident. Further interviews with the resident and staff confirmed that the resident had recently needed help with medications and did not refuse to eat breakfast unless medications were present, contrary to staff assumptions. The staff responsible for completing the assessment had not directly discussed the process or the resident's preferences with her, and there was confusion among staff about the criteria required for self-administration. The deficiency was identified due to the lack of a completed assessment and physician order prior to allowing the resident to self-administer medications.
Failure to Investigate and Resolve Resident Grievance Regarding Staff Cell Phone Use
Penalty
Summary
The facility failed to document a thorough investigation and did not resolve a grievance as required by its own policy for one of four residents reviewed for grievances. A resident expressed concern during a Resident Council meeting about staff using personal cell phones while working. The concern was not entered into the facility's grievance log, and there was no documentation of an investigation or resolution. The Activities Director recalled the concern being brought to the previous Director of Nursing but was unsure if any follow-up occurred. The resident confirmed that no one had followed up with her regarding her concern, which remained unresolved at the time of the survey. Surveyors directly observed multiple staff members, including LPNs, using personal cell phones during work hours for non-work-related activities, such as opening a bank account, making a Facetime call, and discussing a resident. The Director of Nursing stated that there was no specific grievance documented regarding cell phones, although staff had reviewed cell phone expectations previously. The facility's policy requires the Grievance Official to oversee the grievance process, including receiving, tracking, investigating, and resolving grievances, as well as notifying the complainant of the outcome. These steps were not followed in this case.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
A deficiency occurred when a resident with dementia, seizure disorder, psychotic and mood disturbances, and moderate cognitive impairment was placed in a Broda chair with the brakes engaged while seated at the dining table. The brakes, located on the back lower wheels of the chair, were not accessible to the resident, preventing her from moving the chair independently. Multiple observations by the surveyor confirmed that the resident remained in this position for an extended period, attempting unsuccessfully to move the chair by grabbing the wheels, but was unable to do so due to the locked brakes. Interviews with facility staff revealed inconsistent understanding regarding the resident's ability to self-propel in the Broda chair and whether locking the brakes constituted a restraint. The facility's own policy defines a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. Despite this, the resident was repeatedly observed with the brakes engaged, restricting her movement, and staff acknowledged that this could be considered a restraint. The care plan indicated the resident required assistance with mobility and had a history of falls, but did not specify the use of restraints for medical treatment.
Failure to Develop and Implement Person-Centered Care Plans Addressing Communication and Religious Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed the individual needs, preferences, and cultural requirements of three residents. For one resident with Alzheimer's disease and polyosteoarthritis, the care plan included the use of interpreter services to communicate in her preferred language, Nepalese. However, interviews with staff revealed that they were unaware of the resident's language, had not used interpreter services, and instead relied on gestures or attempts to use translation apps, which were unsuccessful. The care plan's instructions for using interpreter services were not followed, resulting in ineffective communication with the resident. Two other residents, both practicing Muslims, did not have their religious preferences or needs reflected in their care plans. One resident expressed distress about being unable to pray as required by her faith due to cleanliness requirements and the lack of a clean space. The other resident reported being denied access to the chapel for prayer and felt that staff did not consider individual religious needs. Despite both residents voicing these concerns, their care plans did not include any focus, goals, or interventions related to their religious practices or preferences. Facility policy requires that care plans be person-centered, culturally competent, and include measurable objectives and timeframes to meet each resident's medical, mental, and psychosocial needs. The policy also specifies that the care plan should identify the resident's language and communication tools if the resident is non-English speaking, and should incorporate cultural and religious preferences. The failure to include and implement these elements in the care plans for the three residents led to the cited deficiencies.
Failure to Update Discharge Plan to Reflect Resident's Goals
Penalty
Summary
The facility failed to develop a discharge plan that reflected a resident's goals and needs for one resident reviewed for discharge planning. The resident, who had diagnoses including depression, diverticulitis, and obstructive and reflux uropathy, was assessed as having moderate cognitive impairment. The resident's care plan indicated a long-term stay with the goal of remaining in the nursing home, despite the resident expressing a desire to move to assisted living. The care plan interventions included discussing feelings and goals for placement as needed, involving social services, and arranging for discharge if needed, but did not actively reflect the resident's stated goal of transitioning to assisted living. Interviews revealed that the resident had communicated his wish to move to assisted living to the social worker, who became aware of this goal in mid-January after being contacted by an assisted living facility. The social worker acknowledged working with the resident and his representative on enrolling in a managed care organization to facilitate placement. However, the care plan was not updated to reflect the resident's current discharge goal, despite both the social worker and the director of nursing agreeing that the care plan should have been revised as soon as staff became aware of the change in the resident's goals.
Failure to Honor Residents' Religious Preferences and Choices
Penalty
Summary
The facility failed to ensure that two residents, both practicing Muslims, received care and services in accordance with their comprehensive assessments and care plans, specifically regarding their religious and cultural needs. Both residents expressed that their religious practices, such as praying seven times a day and maintaining cleanliness before prayer, were not accommodated. The care plans for these residents did not reflect their religious preferences or primary language, despite these being significant to their well-being. Progress notes and interviews revealed that one resident was unable to pray as required due to not being provided with adequate opportunities for cleanliness, such as daily showers, and a clean space for prayer. The resident also reported not being offered individualized activities or support for her religious practices, and staff were either unaware of her religious needs or had incorrect information about her faith. The second resident, also a practicing Muslim, reported that he was not allowed to use the chapel for prayer and felt that his individual religious needs were not considered by the facility. Staff interviews indicated a lack of awareness regarding the resident's religious preferences, with some staff only noting dietary restrictions such as not eating pork. The activity director and director of nursing both acknowledged that religious preferences should be included in care plans if residents voice such concerns, but these were not documented or addressed in the care plans for either resident. Facility policies required that care and services be provided in accordance with residents' choices, values, and beliefs, and that care plans reflect these preferences. However, the facility did not follow its own policies, as evidenced by the lack of documentation and accommodation of the residents' religious needs. The deficiency was identified through interviews, record reviews, and observations, which consistently showed that the residents' spiritual and cultural needs were not being met as required.
Failure to Provide Timely ADL Assistance and Maintain Resident Dignity
Penalty
Summary
Two residents with significant care needs did not receive appropriate assistance with activities of daily living (ADLs), specifically in the areas of personal hygiene, grooming, and toileting, as required by their care plans. One resident, who was totally dependent on staff for personal hygiene and oral care due to multiple diagnoses including a femur fracture, failure to thrive, prostate cancer, anxiety disorder, and heart failure, was observed in the dining room in pajamas with unkempt hair and long, scraggly whiskers. Documentation for this resident's bathing, grooming, and hygiene was either missing or marked as not applicable for multiple consecutive days, and only the night shift was documenting these cares. The resident expressed dissatisfaction with his appearance and reported needing assistance with shaving and grooming, which was confirmed by staff interviews indicating a lack of clear guidelines on the frequency of shaving and grooming tasks. Another resident, with diagnoses including Parkinson's Disease, neuromuscular bladder dysfunction, muscle weakness, and cognitive impairment, was observed multiple times in soiled clothing and with a strong odor of urine. This resident required two-person assistance with transfers and toileting, as documented in the care plan, and was to be changed every two hours. However, staff interviews revealed that the resident was often left in wet briefs and clothing for extended periods, with some staff admitting that changes were not performed as scheduled, sometimes due to the resident's combative behavior. Documentation of care refusals was inconsistent, with only one refusal recorded in the relevant period, despite staff claims of frequent refusals. Observations and interviews confirmed that both residents did not receive the necessary services to maintain good hygiene, grooming, and dignity as outlined in facility policy and their individualized care plans. Staff failed to provide timely and adequate assistance with toileting and personal care, resulting in one resident being left in urine-soaked clothing and another with unaddressed grooming needs. These failures were corroborated by direct observations, resident interviews, and staff admissions, demonstrating a lack of adherence to established care protocols and policies.
Failure to Follow Physician Orders for Pressure Injury Care
Penalty
Summary
A resident with a stage 4 pressure injury on the left hip did not receive necessary treatment and services consistent with professional standards of practice to promote healing. Physician orders specified that the resident should not be in her wheelchair for more than one hour at a time, must be repositioned every 30 minutes while in the wheelchair, and should not lay on her left hip while in bed. These orders were not incorporated into the resident's care plan or care card, and staff were not consistently aware of or following these specific instructions. Observations by the surveyor revealed that the resident remained in her wheelchair for over an hour without being repositioned, despite verbalizing discomfort. Multiple staff interviews demonstrated inconsistent knowledge of the resident's repositioning requirements, with staff referencing standard protocols or the care card, which did not reflect the individualized physician orders. Staff responses varied, with some stating repositioning should occur every two hours, others indicating twice per shift, and some unaware of the specific restrictions regarding the resident's left hip. The Director of Nursing confirmed that physician orders should be followed as written but was not aware of the specific requirements for this resident. The care plan and care card lacked updates to reflect the physician's orders, and no new interventions were added after a wound infection. The facility was unable to provide a policy regarding pressure injury care when requested by the surveyor. As a result, the resident did not receive care in accordance with physician orders and professional standards, leading to a deficiency finding.
Failure to Provide Adequate Pain Management and Transfer Alternatives
Penalty
Summary
A resident with a history of chronic pain, including diagnoses such as Type 2 Diabetes Mellitus, hemiplegia, osteoarthritis, and rotator cuff pathology, experienced ongoing pain exacerbated by the use of an EZ stand lift for transfers. Despite being cognitively intact and repeatedly expressing that the EZ stand caused significant shoulder pain, the facility did not adequately address her pain needs or seek alternative transfer methods. The resident reported crying multiple times daily during transfers and requested re-evaluation for different transfer options, but received no response from therapy or facility leadership. Facility staff, including CNAs and the social worker, were aware of the resident's pain during transfers, with multiple staff members acknowledging that the EZ stand caused her distress and that she cried during each use. The care plan included interventions to evaluate pain management and check comfort levels, but there was no evidence that the plan was updated or that new interventions were implemented in response to the resident's ongoing complaints. The Director of Nursing and other staff confirmed knowledge of the pain but did not initiate increased pain assessments, care plan revisions, or interdisciplinary team meetings as outlined in facility policy. Medication records showed frequent use of both scheduled and PRN pain medications, and physician notes documented persistent pain despite these interventions. The facility failed to reassess the resident's pain management plan or develop and implement new approaches to transferring, and did not ensure that front line staff were informed of the resident's preferences regarding transfers. As a result, the resident continued to experience daily pain associated with the use of the EZ stand, and her care plan was not revised to address her ongoing needs.
Failure to Assess and Supervise Resident's Use of Lift Chair Resulting in Falls
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for one resident. The resident, who had a history of falls, osteoporosis, depression, and dementia, required substantial to maximum assistance with most activities of daily living and was assessed as cognitively intact. Despite these needs, the facility did not adequately assess or monitor the resident's ability to safely use a lift chair, which was a known risk factor for falls. The resident was first observed sliding out of a recliner, prompting a recommendation from therapy to use non-slip matting. However, after a subsequent fall from the lift chair, the intervention was to unplug the chair due to the resident's lack of safety awareness. The care plan was updated accordingly, but the chair was later plugged back in without documented evidence of a reassessment of the resident's ability to use it safely. This lack of documentation and assessment persisted even after the resident experienced another fall from the lift chair, resulting in a femur fracture. Interviews with facility staff revealed that there was no specific fall prevention education provided to staff during orientation or in the previous six months. Additionally, the facility was unable to provide documentation of discussions or assessments regarding the decision to allow the resident to use the lift chair again. The absence of a thorough assessment and lack of staff education contributed to the resident's repeated falls and injury.
Failure to Follow Prescribed Diet Texture for Resident
Penalty
Summary
The facility failed to follow the prescribed easy to chew (Level 7) diet for a resident with multiple diagnoses, including Parkinson's disease, generalized muscle weakness, reduced mobility, adult failure to thrive, and dysphagia. The resident's care plan and physician orders specified a Level 7: Easy to Chew diet, which is intended for individuals who have difficulty chewing and/or swallowing regular textured foods. Despite these orders, the resident was observed with snacks such as cheese crackers, Cheetos, and potato chips in her room, which are not compliant with the prescribed diet. Interviews with staff revealed that both certified nursing assistants and the speech therapist allowed the resident to have snacks outside of her diet restrictions, citing quality of life and the resident's preferences. The speech therapist acknowledged making exceptions for the resident but did not document these exceptions or communicate them to the interdisciplinary team. The registered dietician confirmed that these snacks were not in compliance with the Level 7 diet and that any quality of life exceptions should have been documented in the care plan, which had not occurred. Further interviews with the resident and her family confirmed that she regularly received and consumed snacks not aligned with her prescribed diet, provided both by staff and family members. The director of nursing acknowledged that the speech therapist's exceptions were not documented and not included in the resident's care plan. There was no evidence of a risk and benefit analysis or an order in the medical record to support deviations from the prescribed diet.
Conflicting Care Plan Entries on Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one resident, resulting in conflicting information regarding the resident's ability to self-administer medication. The resident's care plan contained an undated notation stating that the resident may self-administer scheduled oral medications after set-up, while another intervention dated 05/02/24 indicated that the resident may not self-administer medications and must be observed taking them. Additionally, a focus item in the care plan initiated on 01/02/25 set a goal for the resident to be safe in self-administration of medications. However, review of the resident's orders in the electronic medical record did not reveal any order authorizing self-administration of medication. Interviews with staff revealed further confusion, as an LPN stated she was aware the resident could self-medicate based on a special order banner in the EMR, but was unaware of the conflicting care plan entries. The Director of Nursing acknowledged the presence of conflicting information in the care plan regarding the resident's self-medication status. The resident in question had a history of multiple diagnoses, including malignant neoplasm of the ileum, urinary tract infection, sepsis, acute respiratory failure, diabetes, depression, mild cognitive impairment, and insomnia, and was assessed as cognitively intact.
Failure to Ensure Proper Installation and Testing of Bed Rails
Penalty
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails for four residents, identified as R3, R6, R7, and R8. The deficiency was identified through observation, interviews, and record reviews, revealing that bed rails were installed without conducting a Bed System Measurement Device Test to ensure proper installation and reduce the risk of entrapment. The facility's policy requires that physical devices, including bed rails, be reviewed for safety and used according to the manufacturer's recommendations, with regular inspections to prevent safety hazards. For resident R3, the surveyor observed a gap between the bed rail and the mattress, indicating improper installation. The Maintenance Supervisor (MS C) admitted that a newly hired employee, who had not been trained on the measurement device, was installing bed rails. MS C also acknowledged that several installations had not been tested for entrapment points. The facility provided a Bed System Measurement Device Test for R3 dated after the surveyor's request, with no prior documentation of testing. Similarly, residents R6, R7, and R8 had bed rails installed without prior testing documentation. The facility's records indicated order dates for the bed rails, but no evidence of testing before the surveyor's intervention. The Nursing Home Administrator (NHA A) confirmed that testing should occur upon installation, but the facility lacked documentation of actual installation dates, relying instead on order dates. This oversight in testing and documentation led to the deficiency identified by the surveyors.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, leading to a fall incident. The resident, who was cognitively intact and required assistance from two staff members for bed mobility and transfers, fell out of bed when a CNA attempted to assist her alone. The resident's care plan and Kardex clearly stated the need for two-person assistance, but this was not followed, resulting in the resident sliding off the bed and becoming wedged between the bed and the wall. The incident occurred while the CNA was assisting the resident with toileting, and the resident's head was caught between the bed and the side rail, although she later clarified that her head was lower than the side rail. The facility's failure to ensure all staff were trained and aware of the resident's care plan contributed to the incident. The resident reported that staff frequently assisted her alone, despite the care plan's requirement for two-person assistance, and this practice continued even after the fall. The Nursing Home Administrator was unaware of the frequency of single-staff assistance and acknowledged that not all staff had been educated on following the Kardex. Additionally, several staff members, including the CNA involved in the incident, had not received the necessary education or competency testing as part of the facility's post-event action plan.
Resident Burned by Hot Coffee Due to Lack of Safety Protocols
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents, as evidenced by an incident involving a resident who sustained burns from hot coffee. The resident, who was cognitively intact but had physical impairments including quadriplegia, was served coffee in bed. The coffee was served at a temperature of 185 degrees Fahrenheit, which was not monitored or adjusted for safety. The resident attempted to switch the coffee cup from his left hand to his right hand, which was weaker, resulting in the coffee spilling and causing burns to his right flank and buttocks. The facility did not have a process in place for assessing the safety of serving hot liquids to residents, nor were there any specific care plans addressing the risks associated with hot liquids for this resident. The staff routinely provided the resident with coffee in his personal thermos cup without conducting any safety assessments or monitoring the temperature of the coffee. The incident report and interviews with staff revealed that there was no established protocol for ensuring the safe handling of hot beverages by residents, particularly those with physical impairments. Interviews with staff indicated a lack of awareness and training regarding the risks of serving hot liquids to residents. The facility's policy on food safety and preventing burns was not effectively implemented, as staff were not monitoring the temperatures of hot beverages at the point of service. The absence of a structured process for evaluating residents' ability to safely handle hot liquids contributed to the incident, highlighting a significant oversight in the facility's safety protocols.
Inadequate Monitoring and Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic and antipsychotic medications was free from unnecessary medications. The resident, who was admitted with diagnoses including Alzheimer's Disease and Generalized Anxiety Disorder, was prescribed Seroquel and Lorazepam without an appropriate diagnosis for antipsychotic medication. The facility's policy requires that antipsychotic drugs should not be used unless the resident's medical record clearly indicates specific conditions, which was not the case for this resident. The facility did not adequately track quantitative measurements during behavior tracking, which is necessary to measure the efficacy of medication therapy. The resident's Treatment Administration Record (TAR) showed numerous instances where behavior monitoring and side effect monitoring were not properly documented. Instead of recording the number of episodes or using 'Y' or 'N' to indicate behaviors and side effects, staff frequently used 'X' or check marks, which are not appropriate according to the facility's Director of Nursing. Interviews with staff, including RNs, CNAs, and the DON, revealed that the resident's behaviors were not persistent or harmful to themselves or others, contradicting the need for antipsychotic medication. The staff indicated that the resident could be verbally aggressive but was easily redirected and not physically aggressive. The lack of proper documentation and monitoring of the resident's behaviors and medication side effects contributed to the deficiency identified by the surveyors.
Inadequate Supervision and Dietary Compliance Leads to Choking Incidents
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to dietary restrictions for a resident with a history of dysphagia and aspiration events. The resident, who has diagnoses including Parkinson's Disease, dementia, and chronic dysphagia, experienced two choking incidents within a month. On the first occasion, the resident choked on a hot dog, requiring the Heimlich maneuver and hospitalization for acute hypoxic respiratory failure and aspiration pneumonitis. Despite this incident, the facility did not adequately supervise the resident's meals, leading to a second choking event. During the second incident, the resident was served a bowl of honeydew melon, which was not consistent with the prescribed Level 6 soft and bite-sized diet. This resulted in another aspiration event and subsequent hospitalization. Interviews with staff revealed a lack of clarity and responsibility regarding the verification of meal tickets and the appropriateness of food served. The CNA and dietary staff were both identified as responsible for ensuring the correct diet was served, yet the resident received inappropriate food items, leading to the choking incident. The facility's care plan and dietary restrictions for the resident were not followed, contributing to the immediate jeopardy situation. The resident's care plan indicated a need for supervision during meals and specific dietary restrictions, which were not adhered to. Staff interviews highlighted issues with communication and training regarding diet textures and meal ticket verification, which were factors in the deficient practice.
Removal Plan
- The facility will complete mock drills and competency tests for all licensed nursing staff including how to support a resident with partial obstructed airway, choking, Heimlich etc.
- The facility will educate nursing, culinary and activities staff on altered diets/IDDSI. The training will include how to determine foods/fluids safe to consume on prescribed/altered diets. A competency will be completed following education.
- The facility will provide instruction to culinary, activities and nursing staff on where to find a resident's diet.
- The facility has created a system where all meal tray cards for residents on an altered diet will be printed in a different orientation format, so it will be easily recognizable to staff to determine the appropriate diet and food/fluids safe to consume per the prescribed diet.
- The facility will ensure that a licensed nurse is assigned to each dining room.
- The facility will audit all resident diet orders, tray cards, care plan and Kardex to ensure correct orders and that orders match and include ST recommendations for residents who have been on ST caseload.
- The facility will complete meal audits to ensure receiving proper diet breakfast, lunch, and dinner in 2 dining rooms each meal.
- The facility will audit all employee records for licensed nurses to ensure CPR certification. The facility will ensure a licensed nurse is assigned to each dining room during all meals.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) had documented performance reviews conducted annually, as required by the facility's policy. The policy, titled Competency Assessment and Validation, mandates that competency should be assessed annually to ensure all employees are competent in their assigned responsibilities. However, the surveyor's review of the CNA performance review documentation revealed that the last evaluations for CNAs J, K, and L were conducted in 2022, despite their employment at the facility for over a year. Specifically, CNA J was last reviewed on April 18, 2022, CNA K on April 24, 2022, and CNA L on February 27, 2022. During an interview with the facility's new Nursing Home Administrator (NHA M), Chief Executive Officer (CEO N), and Regional Director (RD O), it was indicated that the facility's practice was to conduct CNA evaluations every three years, contrary to the annual requirement stated in the policy. The facility provided the most recent evaluations from 2022 but could not provide any additional documentation to support compliance with the annual review requirement. This discrepancy between the facility's policy and practice led to the deficiency identified by the surveyor.
Failure to Notify Physician of Medication Unavailability
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a need to alter treatment, specifically for a resident who was not administered a prescribed medication. The resident, who was admitted with diagnoses including Vitamin B Deficiency, Multiple Sclerosis, and Muscle Weakness, had an order for Vitamin B Complex-C Oral Capsule to be taken daily. However, the medication was not available from 6/13/24 onwards, and the facility did not notify the resident's physician about this issue. The facility's policy requires immediate notification of the physician in cases of significant treatment alterations, but this was not adhered to. The Assistant Director of Nursing (ADON) was informed of the medication error but did not notify the physician. The Director of Nursing (DON) expected the physician to be informed and the medication to be obtained within 48 hours, which did not occur. The failure to notify the physician and obtain the medication as per the facility's policy led to the deficiency identified by the surveyors.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure the prompt resolution of a grievance reported by a resident, identified as R8, who is cognitively intact with a BIMS score of 15 and has medical conditions including diabetes, heart failure, and reduced mobility. R8 reported an incident where an agency CNA left her room without setting up her meal, leaving her unable to eat. R8 expressed feelings of sadness and vulnerability due to the incident. The charge nurse, RN C, was informed of the situation and reported it to the Director of Nursing (DON B) via text message. However, the grievance was not followed up on by DON B, and it was not filed as a formal grievance as required by the facility's policy. The incident occurred during dinner time when CNA E left R8's room to retrieve a clothing protector, and R8 allegedly called CNA E a derogatory name. CNA D intervened, assisted R8 with her meal setup, and reported the incident to RN C. Despite these actions, the facility's grievance policy, which mandates prompt resolution and communication with the resident, was not adhered to, as DON B did not take further action to address the grievance. This lack of follow-up and formal documentation of the grievance constitutes a deficiency in the facility's grievance handling process.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a resident to the State Agency as required by state and federal regulations. The incident involved a resident whose daughter emailed the Nursing Home Administrator (NHA) alleging that a Certified Nursing Assistant (CNA) was yelling at her mother. According to the facility's Abuse, Neglect, and Exploitation Policy and Procedure, such allegations must be reported immediately to the administrator and the State Agency within two hours of forming the suspicion. However, the facility did not adhere to this policy. The grievance was documented in the facility's Grievance Log, indicating that the NHA reached out to the resident's daughter for more details about the incident, such as the date, time, and witnesses. The daughter did not respond to the NHA's request for additional information, leading the NHA to close the grievance due to a lack of information. During an interview with a surveyor, the NHA acknowledged that the allegation of yelling constituted verbal abuse and should have been reported, but it was not.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse involving two residents. For one resident, an allegation of neglect was reported, indicating that care was not provided during the night shift, resulting in the resident being found soaked with urine. The investigation was incomplete as it did not include interviews with day shift staff or other residents, and there was no documentation of investigative procedures for non-interviewable residents. The Director of Nursing acknowledged that a thorough investigation was not conducted. In another case, a grievance was filed by a resident's daughter, alleging verbal abuse by a CNA. The Nursing Home Administrator initially closed the grievance due to a lack of response from the complainant. However, upon further review, it was found that some investigation had been conducted, including staff interviews and an interview with the resident. Despite this, there was no follow-up with other residents who might not be able to voice their concerns, and the grievance log was not updated to reflect the investigation. The facility's policy requires timely and thorough investigations of all abuse allegations, but these incidents demonstrate a failure to adhere to these procedures. The lack of comprehensive investigations and documentation highlights deficiencies in the facility's response to abuse allegations, as confirmed by interviews with the Director of Nursing and the Nursing Home Administrator.
Failure to Prevent and Manage Pressure Injury in Resident
Penalty
Summary
The facility failed to implement professional standards of practice to prevent and manage pressure injuries for a resident identified as R3, who was at risk for pressure injuries due to her medical conditions, including Type 2 Diabetes Mellitus. Despite being cognitively intact and having a Braden Scale score indicating risk, the facility did not include daily diabetic foot checks in R3's physician orders. The care plan for R3 noted the risk for skin integrity issues but did not adequately address the specific needs related to her condition. R3 developed a pressure injury on her left foot bunion, which was initially noted as a red, blanchable area. Over time, the condition worsened, leading to an open wound that became infected, necessitating the use of oral antibiotics. The facility's documentation showed that interventions were not promptly implemented when the reddened area was first observed. The facility also failed to assess the cause of the redness and did not evaluate R3's footwear, which was later identified as a contributing factor to the injury. Interviews with nursing staff and the Director of Nursing revealed that there was a lack of immediate intervention and assessment regarding R3's condition. The staff acknowledged that interventions should have been put in place earlier to prevent the development of the pressure injury. The facility's oversight in not conducting daily diabetic foot checks and not addressing the footwear issue contributed to the development and subsequent infection of the pressure injury on R3's bunion.
Failure to Provide Daily Diabetic Foot Care
Penalty
Summary
The facility failed to provide diabetic foot care in accordance with professional standards of practice for a resident with Type 2 Diabetes Mellitus. The facility's policy, revised in October 2022, mandates daily foot care for diabetic residents to maintain mobility and foot health. However, the resident in question did not have a physician order for daily diabetic foot checks, which resulted in the absence of this task on the Treatment Administration Record (TAR). Consequently, the nursing staff did not perform or document daily foot checks for the resident. Interviews with nursing staff revealed that diabetic foot checks were only completed if they appeared on the TAR, which requires a physician's order. The Director of Nursing (DON) acknowledged that foot checks were conducted weekly during routine skin checks on shower days, contrary to the facility's policy. The DON expressed skepticism about the feasibility of daily checks and was unable to provide an alternative policy to the surveyor.
Failure to Maintain 1:1 Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for a resident who was supposed to be under 1:1 supervision. The resident, who had been admitted with diagnoses including frontotemporal neurocognitive disorder and muscle weakness, had recently returned from a hospital stay and was noted to wander around the unit. Despite the need for close supervision, the resident's care plan did not include information about 1:1 supervision. On the day of the incident, a CNA assigned to supervise the resident left the resident unattended, resulting in the resident falling in the hallway. During the survey, the RN on duty confirmed that the resident was supposed to be under 1:1 supervision and that the CNA should not have left the resident alone. The CNA acknowledged that she should have stayed with the resident until someone else could take over. The Director of Nursing also confirmed that the resident was considered to be on 1:1 supervision and that staff should not leave such residents unattended. This lack of supervision led to the resident's fall, highlighting a failure in maintaining the required level of care and supervision for the resident's safety.
Failure to Provide Required Medication to Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R5, who had a physician's order for Vitamin B Complex-C Oral Capsule. The medication was not available for administration from 6/11/24 and from 6/13/24 through 6/27/24. R5 was admitted with diagnoses including Vitamin B Deficiency, Multiple Sclerosis, and Muscle Weakness, and had an order to receive the supplement daily. The facility's policy requires the provision of pharmaceutical services to ensure the accurate acquisition, receipt, dispensing, and administering of all drugs and biologicals. Interviews with facility staff revealed a breakdown in communication and procedure regarding the medication's availability. RN F reported the issue to the nurse manager and ADON G, indicating that the medication was not provided by the pharmacy as expected. ADON G confirmed a medication error report was completed and noted that the pharmacy claimed they did not have an order for the medication, despite previous orders. DON B indicated multiple attempts to communicate with the pharmacy to resolve the issue, but the medication was still not received. This deficiency highlights a failure in the facility's pharmaceutical service procedures, impacting the resident's care.
Inadequate Infection Prevention and Control Program
Penalty
Summary
The facility has not established an effective infection prevention and control program, which has the potential to affect all 106 residents. The facility failed to ensure daily infection control surveillance for staff, resulting in incomplete infection control line lists for both staff and residents. Additionally, the facility's monthly infection control rates were not calculated according to current standards of practice, and the March 2024 COVID outbreak summary was found to be incomplete and inaccurate. During an interview, the LPN/IP indicated that the facility does not have documentation of daily surveillance for staff and was unsure when this was last completed. The staff call-in logs reviewed by surveyors were found to be incomplete, with many entries lacking symptomology. This lack of daily surveillance prevents the facility from ensuring correct exclusionary criteria, return-to-work dates, and the ability to prevent, identify, report, investigate, and control infections and communicable diseases. The infection control line lists for residents and staff were also found to be incomplete. For example, the Resident LTC Respiratory Surveillance Line List for January 2024 contained missing information such as the type of test ordered, pathogen detected, and symptom resolution. Similarly, the Staff LTC Respiratory Surveillance Line List for January and February 2024 lacked critical information such as the date last worked, type of test ordered, pathogen detected, and return-to-work dates. Additionally, the March 2024 COVID Outbreak Summary did not match the line list information, indicating that six staff members were not identified in the outbreak summary. Furthermore, an observation revealed that a CNA did not disinfect a resident's bedside table after placing a urinal on it, posing a risk of cross-contamination. The facility's infection prevention and control program was found to be lacking in several areas, including daily surveillance, accurate and complete line lists, and proper calculation of infection control rates. These deficiencies highlight the need for a more organized and effective infection control program to ensure the safety and well-being of residents and staff.
Failure to Complete PASARR Level II Screens
Penalty
Summary
The facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II for residents who stayed longer than 30 days, despite initial exemptions. This deficiency affected four residents who had serious mental illnesses or intellectual disabilities and were on psychotropic medications. The facility's policy required a PASARR Level I screen for all new admissions and a Level II screen if the stay exceeded 30 days, but this was not adhered to for the residents in question. Resident R41, with diagnoses including Generalized Anxiety Disorder and Depression, and on Risperidone, did not have a PASARR Level II screen completed after exceeding the 30-day exemption. Similarly, Resident R89, with Major Depressive Disorder and Anxiety Disorder, and on Duloxetine, also lacked a PASARR Level II screen. Resident R36, with Major Depressive Disorder and on Lexapro, and Resident R103, with bipolar disorder and on multiple psychotropic medications, were also not screened as required. The Director of Nursing indicated a change in responsibility for completing PASARR assessments led to these oversights, and the Nursing Home Administrator acknowledged the deficiency, noting a gap in social worker staffing.
Lack of Adequate Activity Program for Residents
Penalty
Summary
The facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This deficiency affected seven residents who voiced concerns during the Resident Council about the lack of activities, particularly on weekends and evenings. The facility's policy, issued in February 2021, mandates that activities should be appropriate, stimulating, and promote the well-being of residents, considering their individual differences and interests. However, the facility's activity schedule showed limited activities on Saturdays and none on Sundays, failing to meet these requirements. Residents R41, R79, R24, R42, R53, R22, and R59 expressed dissatisfaction with the activity program, noting that there were only one-hour activities on Saturdays and no activities on Sundays. They specifically mentioned missing church services on Sundays, which they used to attend with their families. The activity staff, including the Activity Aide and Activity Director, confirmed the limited scheduling and acknowledged the residents' concerns. They mentioned efforts to find volunteers to lead weekend activities but had not succeeded yet. The Nursing Home Administrator was aware of the residents' complaints and agreed that the activity staff should offer more activities during evenings and weekends. Despite this awareness, no changes had been implemented to address the deficiency. The facility's current activity schedule and staffing did not support the residents' needs for more frequent and varied activities, particularly on weekends and evenings, leading to the deficiency noted by the surveyors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled in accordance with currently accepted professional practices. In one of the medication rooms and several medication carts, surveyors observed multiple instances of undated, open stock medications, medications that should have been refrigerated but were not, and medications with illegible expiration dates. Additionally, different medication administration routes were co-mingled in the same bag, and some medications were found without any labels or resident identification. In one instance, an open vial of Tuberculin purified protein was found without a documented open date, and the RN was unable to state how long the vial had been open. Similarly, a bottle of Florajen was found without an open date or a date indicating when it was removed from the refrigerator. Other examples included undated eye drops, nasal sprays without resident labels, and medications stored together that should have been separated according to their administration routes. Further observations revealed expired medications, such as Latanoprost eye drops and Fluticasone nasal spray, which were not discarded after the recommended period. Additionally, some medications requiring refrigeration, like Promethegan suppositories, were found in medication carts instead of being stored in the refrigerator. The Director of Nursing confirmed that these practices were not in line with the facility's medication storage policy and manufacturer recommendations.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility did not adhere to its antibiotic stewardship program, resulting in inappropriate antibiotic use for several residents. One resident continued an antibiotic for three days without an appropriate indication, and another was ordered and took an antibiotic without meeting the infection criteria. Additionally, a third resident was given an antibiotic before test results were returned and continued to take it despite the lack of appropriate indications for its use. A fourth resident received a prophylactic antibiotic for several months without a clear rationale or end date indicated. The facility's policy on infection prevention and control, which includes an antibiotic stewardship program, was not followed. The Licensed Practical Nurse/Infection Preventionist (LPN/IP) did not always document discussions with providers regarding the necessity of antibiotics, and in some cases, did not contact the provider at all. This led to residents receiving antibiotics without meeting the infection criteria or without proper documentation and rationale for their use. Interviews with staff revealed that there were lapses in following up on antibiotic orders and clarifying the duration of antibiotic use. The Director of Nursing (DON) and other staff members acknowledged that they did not always ensure that antibiotics were prescribed and continued based on appropriate indications and current standards of practice. This lack of adherence to the antibiotic stewardship program resulted in unnecessary and prolonged antibiotic use for the residents involved.
Resident Served Cold Food
Penalty
Summary
The facility did not ensure that food and drink were palatable, attractive, and at a safe and appetizing temperature for one resident observed during dining. The resident, who has dementia and requires moderate assistance for eating, was observed sitting at a dining room table asleep in her wheelchair with a plate of food in front of her. The food remained in front of the resident for approximately 34 minutes before a CNA began feeding her. At that time, the surveyor requested the temperature of the lasagna, which was found to be 113 degrees Fahrenheit. The facility staff then replaced the resident's food.
Failure to Report Alleged Abuse and Missing Narcotics
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the administrator and other officials, and that residents were protected during the facility's investigation. In the case of one resident, the facility did not suspend the staff member named in the abuse allegation as required by the facility's Abuse Policy and Procedure. The Director of Nursing (DON) and Nursing Home Administrator (NHA) determined that the incident was a customer service issue rather than abuse, despite the complainant using the term 'abuse.' The staff member continued to work during the investigation, although not with the resident involved in the allegation. In another instance, the facility failed to report a missing narcotic pain patch for a resident. The nurse who discovered the missing patch reported it to the nurse manager on duty, but the information was not relayed to the DON or the administrator. The DON confirmed that such incidents should be reported up the chain of command and could be considered potential misappropriation or diversion. The facility did not report the missing narcotic patch to the state agency until the surveyors brought it to their attention. These deficiencies highlight the facility's failure to follow its own policies and procedures for handling allegations of abuse and missing narcotics. The lack of immediate reporting and appropriate protective measures for residents during investigations compromised the facility's ability to address and resolve these serious issues effectively.
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 285 citations issued within 25 miles in the last 12 months — including the 12 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 Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hebron Oaks | 1.5 mi | ★★★★★ | 3 | 0 |
| Badger Prairie Hcc | 1.8 mi | ★★★★★ | 0 | 0 |
| Four Winds Manor | 2.3 mi | ★★★★★ | 2 | 0 |
| Oak Park Place Of Nakoma | 3.2 mi | ★★★★★ | 19 | 0 |
| Middleton Village Nursing And Rehab | 5.4 mi | ★★★★★ | 21 | 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 August 2026) and official state health department websites.