Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Edenbrook Lakeside during CMS and state inspections, most recent first.
A resident rolled out of bed during in-bed care when a specialty air mattress was not secured properly to the bedframe, and the resident later was found to have an L2 lumbar fracture. Surveyors also observed a CNA transfer another resident, who was assessed for 1-assist transfers with a gait belt, without using the gait belt despite it being available.
Failure to Use Required PPE During EBP Care: A resident with wounds and an EBP care plan received morning hygiene and toileting assistance from CNAs who wore gloves only and did not wear gowns during high-contact care. The resident had pressure injuries and partial thickness wounds, and staff were observed providing bathing, dressing, incontinence care, and toileting without the required PPE. Staff responses showed confusion about the resident’s precautions and the EBP sign was not consistently present on the room door.
A facility failed to ensure safe inspection and fit of resident beds and air mattresses. One resident with multiple chronic conditions had an air mattress with an approximately five-inch gap between the mattress and foot board on repeated observations, and staff were unclear who was responsible for correcting it. Another resident fell from bed when a broken clip securing the air mattress strap to the frame allowed the bed to lift; surveyors later observed the mattress was too wide for the bedframe, with about five inches hanging over the side and not fully supported.
A facility failed to provide ordered pressure injury prevention and wound care for multiple residents with or at risk for PI. Residents developed sacral, heel, buttock, and coccyx wounds while the facility did not consistently use air mattresses, turn/reposition programs, heel offloading, care plan revisions, or ordered treatments. One resident’s sacral wound became infected and required IV antibiotics and hospitalization, and another resident’s heel wound was later associated with suspected osteomyelitis.
The facility failed to consistently designate a licensed nurse as charge nurse on each shift and did not staff according to its own facility assessment and stated minimum ratios, especially on weekends. Nursing schedules reviewed over a 30‑day period did not clearly identify a charge nurse for every tour of duty, and leadership acknowledged reliance on informal knowledge and an on‑call rotation rather than documented assignment. The facility assessment outlined higher nurse and CNA staffing levels by floor and shift, based on census and acuity, than those actually scheduled, and surveyor review showed reduced weekend staffing over several months, contributing to a pattern of excessively low weekend staffing affecting all residents.
A respiratory therapist with an expired and non-renewed license continued to work in a respiratory therapist capacity, monitoring and providing care for an average of 14 residents with tracheostomies. The facility lacked a credentialing policy for respiratory therapists, and responsibility for tracking licenses had been assigned to a former HR manager. The NHA was unaware of the license lapse until shortly before the survey, while the SDD reported using tracking tools but confirmed that the departed HR manager had been responsible for monitoring this therapist’s license status.
Expired and improperly labeled medications were found in medication carts, including an expired stock bottle of acetaminophen, two expired blister packs of hydralazine for a resident, and an expired blister pack of cyclobenzaprine for another resident. Surveyors also found an opened Lispro insulin pen for a resident that was not dated when opened. Staff stated the carts were checked by the supervisor and that insulin pens are dated when opened, but the observed pen was not dated.
Infection prevention and control practices were not maintained during resident care and medication administration. A CNA did not perform hand hygiene between contaminated and clean tasks during incontinent care, another CNA did not wear the required gown and gloves for a resident on EBP and also failed to perform hand hygiene after glove removal, an LPN touched a resident’s meds with bare fingers while moving pills between cups, and an RN used a G-tube syringe after it fell on the floor and was only rinsed off.
A resident with multiple medical conditions and an identified ADL self-care deficit was care planned to receive one-person assistance with bathing, dressing, and personal hygiene, with showers scheduled twice weekly. Over several days, the resident was observed with disheveled, later matted, hair and wearing the same clothing, while review of records showed no showers provided since admission and no documentation of any refusals in the EMR, despite facility policy requiring documentation and re-approach of refusals. Staff interviews revealed uncertainty about whether the resident had refused showers and an ADON assertion that the resident should have bathed at home during a pass, while the resident reported not having time to shower at home and expressed a desire for a shower, demonstrating that necessary ADL services for bathing and grooming were not provided or documented as required.
A resident with intact cognition and documented preferences for choosing clothes was repeatedly observed wearing a hospital gown while eating and moving about the facility, despite stating a preference for regular clothing and having only one change of clothes. Another resident with multiple chronic conditions was repeatedly observed in the same soiled shirt and pants with dried food and liquid, and stated there were no other clothes available. Staff interviews confirmed the residents lacked appropriate clothing options during the survey observations.
The facility did not document that two residents participated in their person-centered care planning. One resident was cognitively intact and stated not knowing what was going on with discharge planning or recalling any care conference, while the other resident, who was alert and oriented, stated no meeting had been held to discuss discharge plans and that no one had explained medications or care planning. Surveyors found no EMR documentation of an IDT care conference or resident/representative participation for either resident.
Improper Self-Administration of Medications: A resident with heart failure and intact cognition was observed with medication cups containing pills left at the bedside and later holding about 11 pills, despite not having a completed self-administration assessment or order. The resident stated the nurse left the medications and that the resident was working on taking them, while the LPN, ADON, and DON confirmed the resident was not assessed or ordered to self-administer medications.
A resident with cognitive intactness and significant ADL dependence was not provided reasonable accommodation when an over-toilet riser with bilateral handles, placed by therapy to support toilet transfers, was removed from the bathroom without a medical or safety reason. The resident said the riser was needed to hold onto during transfers, therapy confirmed it was part of transfer training and recommended its use, and staff were unsure why it had been taken out.
Missing Employee Background Check Documentation: The facility did not follow its abuse screening policy for an employee whose IBIS background check could not be located in the file. The policy required screening prospective employees for a history of abuse, neglect, exploitation, or mistreatment and obtaining a criminal background check through the state system, but the NHA and Staff Development Director reported the IBIS form for the housekeeper hired around that time was missing.
A facility failed to develop comprehensive person-centered care plans for 3 residents. One resident had diagnoses requiring continuous O2 and was observed receiving nasal cannula O2, but no O2 care plan was found. Another resident had physician-ordered tubi grips for BLE swelling/skin integrity, yet the care plan did not address the intervention or related swelling. A third resident had poor PO intake, malnutrition, and a dehydration/fluid maintenance CAA, but no dehydration or fluid monitoring care plan was located during review.
A resident with Parkinson’s disease, aphasia, dysphagia, vascular dementia, hemiplegia/hemiparesis, diabetes, and adult failure to thrive remained on a care plan that still listed hospice services after hospice had ended. RN and ADON interviews confirmed the resident was no longer on hospice, but the care plan and orders still referenced hospice and included interventions tied to hospice care.
Failure to Provide Required Bathing, Hygiene, and Incontinence Care: Two residents with severe cognitive impairment and dependence on staff for ADLs did not receive the bathing and toileting assistance documented in their care plans. One resident received only 1 shower in 30 days, had uncombed and unkept hair, and was later found with a saturated brief after going more than 3 hours without being checked or changed. Another resident received no showers in 30 days and was also observed for over 3 hours without being checked or changed, despite care plan directions for regular incontinence care and showering.
A resident with PVD, cellulitis, and edema was ordered to wear bilateral tubi-grips during the day and remove them at night, but surveyors repeatedly observed the resident without them. The order was not listed on the CNA Kardex or in the care plan, CNAs said they relied on the Kardex for care guidance, and the TAR documented the tubi-grips as in place despite direct observations to the contrary.
Failure to Ensure Ordered Palm Guards Were Worn: Two residents with limited ROM were repeatedly observed without prescribed hand splints/palm guards despite care plans, physician orders, and TAR documentation directing their use. One resident with severe cognitive impairment and diagnoses including intracerebral hemorrhage and hemiplegia was seen multiple times without a right palm guard and left-hand carrot, while another resident with diagnoses including CML, MS, and encephalopathy was repeatedly observed without bilateral palm guards, which were found across the room.
A resident was observed vaping in his room throughout the survey even though the facility policy limited smoking and e-cigarettes to designated areas; the DON and NHA gave conflicting explanations about the room being the vaping area. The facility also failed to provide adequate supervision for two residents with falls: one resident repeatedly lacked ordered bed-parameter interventions during survey observations, and both residents had fall investigations that did not thoroughly document who last saw them, what care had been provided, or whether planned interventions were in place.
A resident with protein-calorie malnutrition, gastroparesis, and dialysis dependence had poor intake, nausea, vomiting, and frequent meal refusal, yet the care plan called for Nepro BID and no current order was in place when surveyed. The RD acknowledged the supplement had been discontinued without a clinical reason, while records showed intake of 0-25%, severe decreased food intake, and malnutrition with ongoing need for added calories and protein.
A resident with severe cognitive impairment and a G-tube did not receive appropriate tube placement monitoring because the physician order to measure tube length every shift was not transcribed into the MAR/TAR. An RN reported checking placement by wall measurement, but the resident’s tube had no visible tic mark, the MAR/TAR did not document the specific tube length, and the visual inspection order was inconsistently charted. The ADON and DON confirmed the measurement order was missing from the MAR/TAR and that there was no documentation showing the tube length and placement were being monitored as ordered.
Oxygen Humidifier Bottle Missing From Concentrator: A resident with acute respiratory failure with hypoxia, CHF, hypoxemia, and HTN had a physician order for weekly and PRN oxygen humidifier bottle changes, but surveyors observed the resident receiving O2 via nasal cannula without a humidifier bottle on the concentrator on multiple occasions. An ADON later confirmed the order existed after reviewing the chart.
A resident was transferred to the hospital without being provided all required transfer notice information, including the reason for transfer, appeal rights, and correct Ombudsman contact details. The forms used by the facility, created and revised by the corporate office, did not meet regulatory requirements, and staff confirmed the missing information.
A resident was denied immediate readmission after hospitalization because facility staff required additional insurance paperwork, despite the resident's Medicaid coverage and no change in clinical status. Miscommunication among staff led to the resident being sent back to the hospital, even though there was no regulatory reason to deny readmission.
A resident with severe cognitive impairment and multiple medical conditions did not receive post-fall assessments as required by the facility's policy. The policy mandates documentation every shift for 72 hours post-fall, but assessments were missing for several shifts following two separate falls. The Director of Nursing confirmed the deficiency during an interview.
A facility failed to maintain ongoing communication with a dialysis center for a resident requiring dialysis, resulting in a lack of documented communication for 12 appointments. The facility's policy mandates reviewing post-dialysis communication, which was not followed. The issue was attributed to the dialysis center not returning the communication binder, and attempts to retrieve information via fax were made. The deficiency was noted by a surveyor and communicated to the facility's administration.
Two residents in the facility did not have comprehensive care plans addressing their specific needs. One resident with a foley catheter lacked a care plan for catheter management, while another resident's care plan inaccurately documented toileting needs despite frequent incontinence. The facility's failure to update care plans reflects a lapse in the interdisciplinary team process and communication.
A resident receiving medications through a G tube did not receive care meeting professional standards when an LPN administered medications without verifying tube placement. The facility's policy requires checking the tube's placement before administering medications, but this procedure was not followed. The Director of Nursing acknowledged the concern, confirming the policy requirement.
A facility's medication error rate was 41.67% due to an LPN failing to flush a resident's G tube with water before and after administering 15 medications, contrary to the facility's policy. The DON acknowledged the policy violation.
A resident with multiple diagnoses did not receive several physician-ordered medications upon admission due to unavailability, and the physician was not notified. The DON confirmed the lapse, which was against facility policy.
A resident did not receive insulin before meals as ordered by the physician. The insulin was administered after meals on multiple occasions, contrary to the facility's policy and the physician's orders. The RN delayed the administration due to concerns about the resident not eating and other issues on the floor. The DON confirmed the discrepancy.
Unsafe Bed Equipment and Transfer Practices
Penalty
Summary
The facility did not ensure an environment free from accident hazards for a resident who was dependent on staff for bed mobility and personal care. The resident had diagnoses including conversion disorder with seizures or convulsions, congenital deformity of the knee, developmental disorder of scholastic skills, and morbid obesity, and was assessed as cognitively intact. During in-bed care, a CNA rolled the resident toward the window to complete incontinence care, and the resident rolled out of bed onto the floor. The resident was later found to have an L2 lumbar fracture after the fall. The resident’s care plan identified the need for staff assistance with bed mobility and transfers, and the resident had a history of falls. The facility’s investigation documented that the resident was positioned on a specialty air mattress, and the incident findings identified a broken plastic clip securing the mattress to the bed frame. The mattress was reported to have flipped upright when the resident was rolled onto her side, allowing the resident to fall to the floor. Surveyor review also found that the resident’s mattress was not properly fitted to the bedframe and overhung the frame, with the mattress able to be easily moved from the bed frame. The facility also did not ensure safe transfer practices for another resident who was assessed to need one staff member and a gait belt for transfers. That resident had diagnoses including polyneuropathy, spinal stenosis, peripheral vascular disease, unspecified visual loss, and a history of falling, with moderate fall risk and moderate cognitive impairment. During observation, a CNA assisted the resident from the toilet to the wheelchair without using a gait belt, despite the belt being available nearby and the resident’s transfer status indicating gait belt use.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for one resident on enhanced barrier precautions. The resident had been admitted with an unstageable deep tissue sacrum and left heel pressure injury and had diagnoses including polyneuropathy, spinal stenosis, peripheral vascular disease, unspecified visual loss, and a history of falling. The resident’s care plan, revised 5/26/26, included enhanced barrier precautions for bilateral lower extremity partial thickness wounds, right greater than left, and an enhanced barrier precautions sign was observed on the resident’s room door on 6/1/26. During morning care on 6/2/26, two CNAs provided hygiene and toileting care to the resident while wearing gloves only and not a gown. One CNA assisted with bathing, dressing, incontinence care, and repositioning the resident, including washing the resident’s upper body, rectal area, and buttocks, applying barrier cream, and changing clothing and incontinence products. The surveyor observed that this CNA had only gloves on and did not wear a gown while performing these high-contact care activities. Later that morning, another CNA assisted the resident in the bathroom with toileting, wiping the resident, pulling up the incontinence product and pants, and transferring the resident back to the wheelchair while wearing gloves only and not a gown. The surveyor asked the infection control preventionist why the sign was not on the door that morning, and the infection control preventionist stated that some residents take it off and that it had been there the day before. The surveyor also asked staff about the resident’s precautions, and one CNA stated she was not aware the resident was on any precautions, while the assistant director of nursing confirmed the resident was on enhanced barrier precautions. When asked about the expectation for enhanced barrier precautions, the director of nursing initially stated standard PPE, then checked the sign and stated gloves and gown for the listed tasks.
Unsafe Bed and Mattress Inspection and Attachment
Penalty
Summary
The facility did not ensure that resident beds, mattresses, and air mattress attachments were properly inspected for safety. Surveyors observed that R110, who had diagnoses including polyneuropathy, spinal stenosis, peripheral vascular disease, unspecified visual loss, and a history of falling, had an air mattress with an approximately five-inch gap between the mattress and the foot board on multiple observations. Staff interviewed during the survey gave inconsistent responses about who was responsible for ensuring the mattress fit the bed frame and who would address the gap, and the Director of Nursing later placed a spacer between the mattress and bed frame. The facility was not able to provide a mattress policy when requested. The facility also failed to ensure safe bed and mattress attachment for R59 after a fall from bed. The incident report documented that while R59 was receiving cares, the bed suddenly lifted on the window side and R59 fell to the floor, sustaining a lumbar spine fracture. The investigation identified a broken plastic clip securing the air mattress strap to the bed frame on the left side. The maintenance director stated he did not routinely check beds after installation and relied on nursing staff to report problems. During survey observations, R59’s mattress was found to be too large for the twin-size bedframe, with approximately five inches of the mattress hanging over the left side and the mattress not fully supported by the frame. Surveyors observed that the mattress could be easily moved from the bed frame because it was not appropriately attached and did not fit in the bed frame brackets. Facility leadership acknowledged they had not been in the room to observe the bedframe before the surveyor’s findings, and the maintenance director confirmed the bedframe had not been routinely checked by maintenance.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to ensure residents with pressure injuries or at risk for pressure injuries received necessary treatment and services to prevent new ulcers and promote healing. Survey findings identified deficiencies for 7 of 8 residents reviewed for pressure injuries, including residents who developed sacral, heel, buttock, and coccyx wounds while in the facility. The report states the facility did not ensure use of ordered pressure-reducing surfaces, turning and repositioning programs, heel offloading, care plan revisions, or completion of ordered treatments for multiple residents. One resident was admitted without pressure injuries and was assessed as at risk, but developed an unstageable sacral pressure injury that later became infected and required IV antibiotics and hospitalization. The record showed the air mattress was care planned before it was actually placed, and the initial skin change was not fully documented with wound location, measurements, and wound bed assessment. The wound progressed from deep tissue injury to necrotic full-thickness sacral injury, and the resident was later hospitalized for excessive drainage from the infected wound. Another resident was admitted without pressure injuries and was assessed as at risk, but developed unstageable heel injuries and a right deep tissue injury. Prior to the wounds, the care plan did not include heel offloading interventions. The resident’s left heel wound was later documented with suspected osteomyelitis, MRI findings suggestive of osteomyelitis, and antibiotic treatment. A third resident admitted with healed unstageable DTIs later developed a sacral wound that was changed to an unstageable pressure injury and declined to a stage 4; the facility did not revise the care plan, the heels were not offloaded, and treatments were not completed according to physician orders. Additional examples included a resident with a stage 4 pressure injury who did not have an air mattress in place as ordered, a resident at risk whose heels were not offloaded during multiple observations, a resident with a stage 3 coccyx pressure injury whose physician orders were not implemented until 4 days after admission and whose mattress was not rated for that wound severity, and a resident whose heels were not offloaded and who did not have the ordered pressure-reducing wheelchair cushion in place. The report states the facility’s failure to provide care to prevent pressure injuries, including air mattress use, turning/repositioning, heel offloading, care plan revision, and completion of ordered treatments, created an Immediate Jeopardy beginning 6/24/25.
Failure to Designate Charge Nurses and Maintain Weekend Staffing per Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff and to designate a licensed nurse as charge nurse for each tour of duty, as required to meet residents’ needs. Review of 30 days of nursing schedules showed that the schedules did not consistently identify who the charge nurse was for each shift, and sometimes listed a charge nurse only for the evening shift. During an interview, the Staff Development Director stated that during the day the DON, assistant DONs, or infection preventionist are in the building and that staff "know" who the evening and night charge nurses are, and referenced an on‑call rotation. However, the facility did not provide documentation or explanation showing that a licensed charge nurse was clearly designated on each shift, and the Nursing Home Administrator acknowledged the concern when interviewed about the schedules. The deficiency also includes the facility’s failure to staff according to its own facility assessment and stated minimum staffing ratios, particularly on weekends. The facility assessment, last reviewed in November 2025, specified licensed nurse‑to‑resident and CNA‑to‑resident ratios and detailed expected staffing by floor and shift, with staffing to be based on census and acuity. In contrast, the Staff Development Director described lower minimum staffing levels actually used on the schedule, and surveyor review of October 2025 schedules showed reduced staffing on weekends compared to both the facility assessment and the Director’s stated minimum ratios. The facility triggered for excessively low weekend staffing from October through December 2025, and both the Staff Development Director and the Nursing Home Administrator acknowledged staffing challenges during that period, with no additional information provided to reconcile the discrepancy between assessed needs and actual staffing. This deficient practice had the potential to affect all 98 residents in the facility.
Unlicensed Respiratory Therapist Provided Tracheostomy Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that specialized respiratory therapy services were provided by qualified, licensed personnel. The facility had an average of 10–18 residents receiving tracheostomy care, with an average census of 14 residents with tracheostomies while Respiratory Therapist (RT)-L was employed. RT-L was hired with a respiratory therapist license that later expired, and RT-L continued to work in a respiratory therapist capacity in the facility after the license expiration date. Review of the Department of Human Services (DHS) online license look-up confirmed that RT-L’s license had expired and that renewal had been denied. Time clock records verified that RT-L continued to work in the role of a respiratory therapist after the license expiration and up until the last recorded work date. The facility did not have a policy for credentialing respiratory therapists, and responsibility for monitoring licenses had been assigned to a human resources manager who was no longer employed at the facility. The Nursing Home Administrator (NHA) reported being unaware that RT-L’s license had lapsed until informed shortly before the survey and acknowledged concern about the situation. The Staff Development Director (SDD) described using a checklist and spreadsheet to track employee licenses and certifications but indicated that the former human resources manager was responsible for monitoring RT-L’s license status. Another respiratory therapist (RT-N) stated that respiratory therapists in the facility are primarily responsible for monitoring all residents with tracheostomies, confirming that RT-L was functioning in this capacity while unlicensed.
Expired and Undated Medications Found in Medication Carts
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with currently accepted professional principles, and expired medications were found in 2 of 3 medication carts. In the first-floor south medication cart, surveyors observed a stock bottle of Acetaminophen 325 mg with an expiration date of 2/2026. In the second medication cart, surveyors observed R95's Lispro insulin pen that had been opened and used but was not dated when opened. Surveyors also observed two blister packs of Hydralazine 100 mg for R45, each containing 30 tablets, with expiration dates of 8/31/25 and 9/30/25, respectively. Surveyors additionally observed a blister pack of Cyclobenzaprine 10 mg for R59 containing 22 tablets that was expired on 2/28/26. The facility's Medication Storage policy states that expired medications are to be removed from medication carts prior to or at the time of expiration and that medications are to be stored in accordance with manufacturer guidance and not to exceed expiration dates unless a shortened shelf-life once opened. When asked, an LPN stated the medication cart was checked by the evening supervisor, and an RN stated insulin pens are dated when opened, but the observed insulin pen for R95 was not dated.
Infection Prevention and Control Failures During Resident Care and Medication Administration
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection during multiple resident care activities. During incontinent care for a resident with acute respiratory failure, congestive heart failure, cognitive impairment, cardiomyopathy, atherosclerotic heart disease, hypertension, an indwelling urinary catheter, and frequent bowel incontinence, a CNA washed the resident’s face, underarms, frontal area, catheter tubing, inner thighs, rectal area, and buttocks, but did not remove gloves and perform hand hygiene before moving from contaminated care to a clean task. The same resident was later assisted with urinary drainage, and the CNA placed a graduate directly on the floor without a barrier before draining urine from the catheter bag. A second resident with quadriplegia, neurogenic bowel and bladder, always urinary incontinence, frequent bowel incontinence, and a Stage 4 pressure injury was on enhanced barrier precautions. During incontinent care, a CNA entered the room without a gown, provided perineal and rectal care, removed gloves and put on new gloves without performing hand hygiene, and later placed a gown on after the care had already begun. The infection preventionist stated that gown and gloves should be worn for incontinent care for a resident on enhanced barrier precautions and said the observed practice was wrong. Medication handling errors were also observed. An LPN preparing a resident’s medications used the tip of her fingernail to move pills from one medication cup to another while verifying the count, and later administered the medications. In another observation, an RN preparing G-tube medication dropped the syringe on the floor, picked it up, rinsed it off with water, withdrew water into it, and used that same syringe to administer the resident’s G-tube medication. The infection preventionist stated that if a syringe is dropped on the floor, a new one should be obtained because the dropped syringe is contaminated.
Failure to Provide and Document Assisted Bathing and Hygiene for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, specifically bathing, grooming, and personal hygiene, to a resident who required assistance. Facility policy on ADLs, revised 2/25/2025, states that residents will receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including assistance with bathing/showering, personal hygiene, and dressing, individualized to resident needs and preferences, with refusals reported to a nurse, re-approached, and documented in the EMR. The resident’s comprehensive care plan dated 3/18/26 identified an ADL self-care performance deficit related to multiple medical conditions, with interventions specifying one-person assist for bathing/showering, dressing, and personal hygiene/oral care, and assistance with clothing selection and dressing. Despite these care plan directives, the resident was repeatedly observed over multiple days with very disheveled hair and wearing the same long sleeve blue shirt and dark gray pants, with hair later noted to be matted in some areas. The CNA assignment book showed the resident was scheduled for showers twice weekly, yet review of shower documentation revealed the resident had not received any showers since admission. The resident reported possibly having had only one shower since admission, was aware that their hair was “wild,” and stated they did not have other clothes to change into. There was no documentation in the EMR of any shower refusals by the resident. Interviews with staff further demonstrated a lack of adherence to policy and care plan. One CNA described the process for re-approaching residents who refuse showers but did not confirm refusals for this resident, stating they had not worked or been assigned to the resident on shower days. The ADON initially stated the resident had refused all showers and that such refusals should be documented in the EMR, but upon review with the surveyor, acknowledged there was no documentation of refusals. The ADON also stated that the resident should have taken a shower at home during a pass, and later questioned the resident, who reported not having time to shower at home and expressed a desire for a shower. These observations and interviews show that the resident did not receive the planned and required assistance with bathing, grooming, and personal hygiene, and that staff did not document any refusals as required by facility policy.
Failure to Maintain Resident Dignity Through Appropriate Clothing
Penalty
Summary
The facility did not ensure that residents were treated with dignity and respect in a manner that promoted quality of life for 2 of 22 residents reviewed for dignity. One resident, who was cognitively intact with a BIMS score of 14 and whose care plan documented a preference to choose clothing and assistance with dressing, was observed multiple times in a hospital gown while eating, sitting in a wheelchair, and propelling the wheelchair in the hallway. The resident stated a preference to wear clothes, especially sweatpants, and said there was only one change of clothes available, the clothes brought on admission. A CNA stated the resident had been seen wearing a gown all the time with a shirt underneath and that if a resident needed a change of clothes, the CNA would go to the supervisor. The resident’s record also documented dependence for toileting, hygiene, showers, upper and lower dressing, and transfers, along with interventions to assist with dressing and to choose comfortable clothing. The surveyor observed the resident in the gown on multiple occasions over several days and informed the NHA, DON, and RDC that the resident preferred clean clothes, but no additional information was provided. A second resident, with diagnoses including rib fracture, repeated falls, CKD, emphysema, Marfan syndrome, malnutrition, depression, and schizophrenia, was observed wearing the same blue long-sleeve shirt and dark gray pants on multiple occasions. The clothes were noted to be soiled with dried food and liquid, and the resident stated there were no other clothes to put on. A CNA stated that if a resident did not have a change of clothes, a gown would be offered, and the ADON stated staff should try to find clothing items and that the facility had donated clothing. The resident later stated that free clean clothes were obtained and was very happy.
Failure to Include Residents in Care Planning
Penalty
Summary
The facility failed to allow 2 residents, R77 and R105, to participate in the development and implementation of their person-centered plans of care. The report states there was no documentation in either resident’s electronic medical record showing that the resident and/or representative participated in care planning, and surveyors were unable to locate documentation that a care conference occurred involving the interdisciplinary team (IDT) for either resident. R77 was admitted with diagnoses including peripheral vascular disease, right lower limb cellulitis, essential hypertension, hypothyroidism, and hyperlipidemia. R77’s admission MDS documented a BIMS score of 14, indicating cognitive intactness for daily decision making. During interview, R77 stated not knowing what was going on with discharge planning and said R77 could not remember having a care conference meeting. Survey review found no documentation of a care planning meeting involving the IDT, R77, or R77’s representative. R105 was admitted with diagnoses including a left rib fracture, repeated falls, chronic kidney disease, emphysema, Marfan syndrome, protein-calorie malnutrition, depression, and schizophrenia. R105 was described as alert and oriented to person, place, and time, and stated that R105 had not met the social worker, had not had a meeting to discuss discharge plans, had no idea what was going on, and had not participated in any meeting. Survey review found no documentation of a care planning meeting involving the IDT, R105, or R105’s representative.
Improper Self-Administration of Medications
Penalty
Summary
The facility did not ensure that one resident was clinically appropriate to self-administer medications. The resident had diagnoses including heart failure and an MDS documenting a BIMS score of 13, indicating intact cognition, but the resident's self-administration of medication assessment was completed with a response of no, indicating the resident was not assessed as safe to self-administer medications. The facility policy titled Medication Self Administration states that a licensed nurse shall complete a screen to determine factors that may affect safe medication administration. Surveyors observed the resident in bed with medication cups containing pills left on the over-bed table and later holding a medication cup with approximately 11 pills. The resident stated that the nurse left the medications and that the resident was working on self-administering them. During observation, there was no licensed nurse or medication tech present to supervise the resident's self-administration. Interviews with the LPN, ADON, and DON confirmed that the resident did not have an order or assessment to self-administer medications and should not have been self-administering them.
Failure to Maintain Adaptive Equipment for Resident Toileting Needs
Penalty
Summary
The facility did not ensure reasonable accommodations were provided for a resident’s needs and preferences when an over-toilet riser with bilateral handles, which therapy had placed to assist with toilet transfers, was removed from the resident’s bathroom without a medical or safety reason. The resident was admitted with peripheral vascular disease, right lower limb cellulitis, hypertension, hypothyroidism, and hyperlipidemia, and the MDS documented a BIMS score of 14, indicating the resident was cognitively intact. The resident’s MDS also documented lower-extremity ROM impairment, dependence for toileting, hygiene, showers, dressing, and transfers, and the CAA stated the resident required staff assistance with ADLs and had a goal of increasing independence. The resident told the surveyor that the over-toilet riser was needed because the resident held onto the riser bars to transfer, but it was gone and the resident did not know why. Surveyors observed no over-toilet riser in the bathroom on multiple occasions. Therapy staff confirmed they had been working with the resident on transfers using the over-toilet riser and recommended its use, and a COTA verified personally placing the riser over the toilet a couple of weeks earlier. A CNA stated the riser may have been mistaken for being used by the roommate who shared the bathroom. During the survey, the COTA brought another over-toilet riser and placed it over the resident’s toilet, and the resident expressed happiness. The facility’s policy stated it would provide reasonable accommodations, including adaptive equipment, to meet resident needs and preferences.
Missing Employee Background Check Documentation
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after interview and record review showed the facility did not follow its abuse screening policy for 1 of 8 employees reviewed. The facility policy titled Vulnerable Adult Abuse and Neglect Prevention required screening potential employees for a history of abuse, neglect, exploitation, or mistreatment and obtaining a criminal background check using the state specified background system. During interview, the NHA stated they would look into missing background check documentation for two sampled employees. Later, the Staff Development Director and NHA reported that after searching all employee files, they could not locate an IBIS background form for Housekeeper-V around the time of hire, and no additional documentation was provided to explain why the background check was not completed before the employee began working.
Missing comprehensive care plans for oxygen, tubi grips, and dehydration
Penalty
Summary
The facility did not ensure a comprehensive person-centered care plan was developed for 3 of 22 residents reviewed. The deficiency involved missing care plans for oxygen use, tubi grips, and dehydration/fluid monitoring. The facility policy stated that the interdisciplinary team will develop an individualized, comprehensive care plan for each resident based on medical condition, medical history, assessments, lifestyle, and current resident goals. R11 had diagnoses including acute respiratory failure with hypoxia, congestive heart failure, hypoxemia, and hypertension. A physician order directed oxygen saturation checks every shift and oxygen at 0-5 L/min to keep saturations at 92% or better via nasal cannula continuously and as needed for shortness of breath. Surveyors observed R11 receiving oxygen via nasal cannula on multiple occasions, including while in bed and while seated in a Broda chair. Review of R11’s care plans showed several active care plans, including respiratory symptoms and risk for respiratory infections, but no oxygen care plan was present at the time of review. When asked how care plans are developed, the ADON stated they are opened upon admission and then adjusted afterward. The DON later provided a care plan for altered respiratory status/difficulty breathing that included oxygen per MD order, but this was not present when the surveyor initially reviewed the record. R77 was admitted with diagnoses including peripheral vascular disease, cellulitis of the right lower limb, essential hypertension, hypothyroidism, and hyperlipidemia. The physician ordered tubi grips size F to both lower extremities in the morning and removal at night to promote skin integrity. R77’s record also documented bilateral lower extremity swelling and pain, and the resident was on a 1500 mL fluid restriction. Surveyors could not locate a comprehensive care plan that addressed the ordered bilateral tubi grips or the lower extremity swelling and pain. Staff were informed that the tubi grips and related swelling concerns were not updated and documented within the comprehensive care plan. R85 was admitted with osteoarthritis, morbid obesity, spondylosis, adult failure to thrive, moderate protein-calorie malnutrition, anxiety disorder, and major depressive disorder. The MDS showed a BIMS score of 15. The dehydration/fluid maintenance CAA identified a goal of adequate fluid intake to prevent fluid deficit, and the hydration assessment noted hospitalization for failure to thrive, multiple wounds, hypoglycemia, poor oral intake, starvation ketosis, and metabolic acidosis with IV fluids given in the hospital. The dietitian stated the facility monitored daily fluid intake and that the resident received water with medications, jello at lunch, and fluids kept within reach. However, surveyors could not locate a dehydration or fluid monitoring care plan for R85, and the care plan addressing risk for dehydration was not in place until after the concern was brought to the dietitian’s attention.
Care Plan Not Updated After Hospice Services Ended
Penalty
Summary
The facility did not update R10’s comprehensive person-centered care plan after R10 was removed from hospice services. The facility’s policy required the interdisciplinary team to develop and revise individualized care plans based on the resident’s condition and to update them when there was a significant change in condition. R10 was admitted with multiple diagnoses including Parkinson’s disease with dyskinesia, aphasia, type 2 diabetes mellitus, conversion disorder, dysphagia, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, vascular dementia, and adult failure to thrive. The significant change MDS dated 2/12/26 coded R10 as receiving hospice care, and the care plan still identified R10 as being on hospice services with interventions directing staff to follow hospice care plans and notify hospice of changes in condition. During interviews, RN-W stated that R10 was no longer on hospice and that the computer still indicated hospice status. ADON-E confirmed that R10 had been removed from hospice about a month or so earlier on 2/1/26, but the care plan and orders still reflected hospice and she did not know why. ADON-E also stated that it would most reasonably be expected to remove hospice services from the care plan after services ended, although it did not change the treatment R10 received. Surveyor review identified three care plans related to hospice services, including one with five interventions instructing staff to utilize hospice services, and the concern was discussed with the NHA, DON, and Regional Director of Clinical Care Services.
Failure to Provide Required Bathing, Hygiene, and Incontinence Care
Penalty
Summary
The facility did not ensure that residents who were dependent on staff for activities of daily living received the necessary assistance for bathing, hygiene, and toileting. The report identified deficiencies for two residents, both of whom had severe cognitive impairment and required staff support for personal care. Facility policy stated that residents should receive appropriate ADL services, that bathing and hygiene assistance should be provided, and that refusals must be documented and reported. One resident, who had dementia, a BIMS score of 00, and was dependent on staff for all ADLs, was supposed to receive showers twice weekly. Survey review of the shower task log showed only 1 shower and 3 bed baths over a 30-day period, with no documented refusals. The resident was observed in the dining room with uncombed hair that appeared unkept. Staff interviews confirmed that the resident should have been showered twice per week and that refusals should have been documented, but no refusal alerts were present in the system. The same resident was also dependent on staff for toileting and had care plan directions to check and change every 2 hours and provide incontinence care as needed. During continuous observation, the resident was not checked or changed for more than 3 hours and was later found with pants wet with urine and a brief completely saturated. Staff were unsure when the resident had last been changed. Another resident, who also had dementia and severe cognitive impairment, was dependent on staff for showering and toileting. Survey review showed no showers in the last 30 days and 4 bed baths, with no documented refusals. The resident’s care plan required incontinence care after each episode and checking and changing as needed, yet during continuous observation the resident was not checked or changed for over 3 hours.
Failure to Follow Ordered Tubi-Grip Treatment
Penalty
Summary
The facility did not ensure a resident received physician-ordered care and treatment when R77 was ordered to wear bilateral tubi-grips during the day and remove them at night to promote skin integrity. R77 was admitted with diagnoses including peripheral vascular disease, right lower limb cellulitis, essential hypertension, hypothyroidism, and hyperlipidemia. The admission MDS documented that R77 was cognitively intact with a BIMS score of 14, had no depressive or behavior symptoms, and required assistance with multiple activities of daily living. The physician order for tubi-grips to both lower extremities was active, but the order was not included on the CNA Kardex and was not included in the comprehensive care plan. During the survey, R77 was repeatedly observed not wearing the ordered tubi-grips on the bilateral lower extremities. Surveyor observations on multiple occasions showed R77 without tubi-grips, including while seated in a wheelchair with legs dangling and no foot pedals in place. R77 told the surveyor that R77 had tubi-grips at home and had been wearing them there but had not been wearing them in the facility. CNAs interviewed stated they would check the Kardex for resident care guidance, and one CNA reported never seeing tubi-grips in R77's room. The ADON also observed and agreed that R77 was not wearing the physician-ordered tubi-grips. The TAR for March 2026 documented the tubi-grips as being on, which did not match the surveyor's observations.
Failure to Ensure Ordered Palm Guards Were Worn
Penalty
Summary
The facility did not ensure that two residents with limited ROM received the prescribed treatment and services to maintain or improve ROM and prevent further decrease in ROM. One resident had diagnoses including nontraumatic intracerebral hemorrhage, chronic kidney disease, depression, encephalopathy, anxiety disorder, polyosteoarthritis, and hemiplegia, and had severe cognitive impairment with an MDS BIMS score of 00. That resident’s care plan and physician order directed staff to keep a right palm guard and left-hand carrot on at all times, removing them daily for hygiene and then reapplying them. During multiple observations over several days, the resident was repeatedly seen without the right palm guard and without the left-hand carrot while in bed and while being wheeled in a Broda chair. On one observation, the resident’s left hand was near the mouth, and on other observations the right hand could not be fully seen because it was under the sheet. The surveyor informed the ADON that the resident had multiple observations without the ordered devices, but no additional information was provided as to why the devices were not being worn according to the physician order. A second resident had diagnoses including chronic myeloid leukemia, multiple sclerosis, and encephalopathy, and the MDS documented impairment of one upper extremity. The resident’s care plan and physician order required bilateral palm guards to be applied in the morning and removed for hygiene and at bedtime, and the TAR showed daily application and removal entries. However, the resident was repeatedly observed in bed without either palm guard, and the palm guards were found on the windowsill across the room. Staff interviews indicated the resident sometimes fought wearing them and that staff should put them on and off during the day, but no additional information was provided as to why the resident was not wearing the prescribed palm guards.
Smoking Hazards and Inadequate Fall Supervision
Penalty
Summary
The facility did not ensure the environment remained free of accident hazards when a resident who was documented as vaping in the facility was observed vaping in his room throughout the survey. The resident had diagnoses including nicotine dependence, contracture of the right hand, and quadriplegia, and was assessed as cognitively intact but dependent on staff for all cares, mobility, and transfers. Although the resident’s care plan and smoking assessment referenced vaping in the room and being safe to vape unsupervised, survey observations documented the resident vaping in the room, with two vape devices charging on the dresser, empty cartridges present, and a key around the resident’s neck for a lock box containing more vape products. The facility’s smoking policy stated that smoking and electronic cigarettes were only allowed in designated smoking areas. During the survey, the DON stated she was aware the resident was able to smoke in the room but had no specifics or documentation, while the NHA stated the facility designated the resident’s room as the vaping area. The surveyor observed the resident vaping in the room on multiple occasions and interviewed the resident, who stated the vape contained tobacco and that the facility had grandfathered the resident in so he could smoke in the room. No additional information was provided regarding the resident’s vaping in the room. The facility also did not provide adequate supervision to prevent accidents for two residents with falls. One resident had diagnoses including hypertension, anxiety disorder, hemiplegia, hemiparesis following cerebral infarction, and diabetes mellitus, and was assessed as cognitively intact and dependent for transfers and toileting hygiene. Although the resident had a fall care plan with interventions including a low bed, gripper socks, extra pillows to define bed parameters, and a wedge cushion, survey observations repeatedly found the resident in bed without the extra pillows or wedge in place. The resident had multiple falls, and the facility’s investigations did not include thorough information such as who last saw the resident, when the resident was last provided incontinence care, or whether prior interventions were in place at the time of the falls. A second resident with diagnoses including diabetes mellitus, encephalopathy, vascular dementia, and hypertension also had multiple falls and was assessed as cognitively intact but requiring assistance with toileting hygiene and transfers. The resident’s care plan included interventions such as a low bed, fall mat cushion at bedside, gripper socks, and placing the bed against the wall with the mat on the exposed side. Survey review found the facility’s fall investigation did not identify when the resident was last provided personal care or toileted, whether prior interventions were in place, or who last saw the resident. One investigation also documented no mat on the floor even though the floor mat was listed as an intervention. No additional information was provided.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility did not ensure that R4 received the therapeutic diet and meal supplement that were documented in the resident’s plan of care for nutritional support. R4 was admitted with diagnoses including unspecified protein calorie malnutrition, gastroparesis, and dependence on renal dialysis. The nutritional care plan and skin integrity plan both documented interventions to provide supplements, including Nepro twice daily, along with monitoring acceptance, and to provide diet, supplements, vitamins, and/or fortified foods per orders. However, surveyor review found no current order for Nepro at the time of the survey even though it remained listed on the care plan. R4’s records showed ongoing poor intake and repeated gastrointestinal symptoms. The RD documented that R4 was on a liberalized regular diet because of recent poor intake, had an overall intake of 0-25%, and that meals, supplements, and other intake did not meet minimum needs. The record also noted multiple reports of nausea, vomiting, and abdominal pain, along with use of pantoprazole, Reglan, and PRN ondansetron. Additional assessments documented severe decrease in food intake over three months, malnutrition, significant changes in weight and appetite, frequent emesis, and that Nepro twice daily was being used to provide additional calories and protein. During interviews, R4 stated that meals were often skipped and that dialysis made the resident feel unwell and nauseous. The RD told the surveyor that the resident had frequent nausea, emesis, and decline in meal intake, and that nursing had addressed symptoms with medications. When asked why there was no current Nepro order, the RD stated it must have been discontinued when R4 returned from the hospital and that there was no clinical reason for it to have been discontinued. Later, the RD stated Nepro had been added as a resident preference and also documented that Nepro was recently added to provide additional calories and protein. The physician order for Nepro was not present until after the surveyor identified that R4 was not originally receiving it per the plan of care.
G-tube Placement Order Not Properly Transcribed or Documented
Penalty
Summary
The facility did not ensure appropriate treatment and services for a resident with a gastrostomy tube. The resident had diagnoses including dementia and acute cystitis with hematuria, and the MDS documented a BIMS score of 00, indicating severe cognitive impairment. The resident was dependent on staff for all ADLs, incontinent of bowel and bladder, and had impairment on both sides in the upper and lower extremities. A physician order required the resident’s G-tube length to be measured every shift for placement verification, with the tube length documented as 16 inches plus or minus 1 cm, and another order required visual inspection of the initial mark on the tube. During observation, an RN administered tube feeding and stated the tube was checked by measuring tape on the wall and charted as complete, but also stated the resident’s tube did not have a visible tic mark. The facility policy required the tube to be marked, the length measured and documented, and the mark visually inspected before access. Record review showed the order to measure the tube length was not transcribed into the MAR/TAR, so nursing staff could not accurately monitor placement using the specific measurement. The MAR/TAR documented the visual inspection order inconsistently, with yes and no entries, and the tube length itself was not documented. The ADON and DON confirmed the measurement order was missing from the MAR/TAR and that there was no documentation showing the tube length and placement were being monitored as ordered.
Oxygen Humidifier Bottle Missing From Concentrator
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for R11, who had diagnoses including acute respiratory failure with hypoxia, congestive heart failure, hypoxemia, and hypertension. R11 had a physician order dated 10/24/25 to change the oxygen humidifier bottle weekly and as needed while receiving oxygen therapy. On 3/23/26, a surveyor observed R11 in bed receiving oxygen via nasal cannula at 1.5 liters per minute, and the oxygen concentrator did not have a humidifier bottle. The same condition was observed again during incontinence care later that morning, and again on 3/24/26 while R11 was in bed receiving oxygen via nasal cannula. On 3/25/26, the ADON reviewed the physician orders and confirmed that R11 did have an order for a humidifier bottle, and the surveyor noted the concentrator had not had a humidifier bottle during the prior observations before R11 was transferred to the hospital.
Failure to Provide Complete Transfer Notice Information
Penalty
Summary
The facility failed to provide all required transfer notice information for a resident who was transferred to the hospital. Specifically, the documentation for the resident's transfer did not include the reason for the transfer, information about appeal rights, the correct contact information for the Ombudsman, or the correct email address for the Regional Field Operations Director for the Division of Quality Assurance. The facility's policy requires that residents and their representatives receive written notice of transfer or discharge, including specific information about the transfer, appeal rights, and contact details for relevant advocacy entities. Review of the resident's medical record showed that the Bed-Hold Agreement - Transfer Notice forms used on two separate occasions were missing required elements. Interviews with facility staff revealed that the forms were created and revised by the corporate office, but even the most recent versions did not meet regulatory requirements. The staff responsible for maintaining these forms confirmed that the necessary information was not included in the documents provided to the resident and their representative.
Resident Denied Readmission Due to Administrative Paperwork Delay
Penalty
Summary
The facility failed to permit a resident to return to the facility immediately following hospitalization, despite there being no clinical or regulatory reason to deny readmission. The resident, who was covered by a managed Medicaid plan and had a legal guardian, was transferred to the hospital and, upon discharge, was ready to return to the facility. The facility's own policy states that a resident whose hospitalization exceeds the bed-hold period should be readmitted if they require the facility's services and are eligible for Medicaid or Medicare. However, when the hospital attempted to discharge the resident back to the facility, the facility refused readmission, citing incomplete insurance paperwork, specifically the absence of a Medicare denial form, even though the resident's Medicaid plan would continue to cover the stay and such a denial was not required. Interviews with facility staff revealed confusion and miscommunication regarding the necessary paperwork for readmission. The Director of Marketing confirmed that all authorizations were believed to be in place, but the Corporate Admissions staff insisted on having a Medicare denial form before readmitting the resident. The Nursing Home Administrator acknowledged misunderstanding the situation and did not allow the resident to return, resulting in the resident being sent back to the hospital. The surveyor confirmed there was no regulatory reason for the denial, and the facility's actions were based solely on internal administrative requirements rather than the resident's clinical status or eligibility.
Failure to Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that a resident received post-fall assessments as per the facility's policy, which requires documentation of the resident's condition every shift for 72 hours following a fall. This deficiency was identified for one resident who experienced falls on two separate occasions. The facility's policy mandates that staff document relevant clinical findings such as vital signs, pain, swelling, bruising, and changes in function or cognitive status after a fall. However, the surveyor found that for the falls occurring on June 29 and August 30, several shifts lacked the required assessments, with five shifts missing documentation for each fall. The resident involved had a history of significant medical conditions, including nontraumatic intracerebral hemorrhage, hydrocephalus, encephalopathy, abnormalities of gait and mobility, cognitive communication deficit, and restless leg syndrome. The resident was also noted to be severely cognitively impaired with impairments to one side of their upper and lower extremities. Despite these conditions, the facility did not complete the necessary post-fall assessments, as confirmed by the Director of Nursing during an interview. The Director acknowledged that the assessments should have been completed as scheduled but admitted that the documentation provided to the surveyor was all that was available.
Failure in Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with a dialysis center for a resident requiring dialysis services, as per professional standards of practice. The resident, who is cognitively intact and has a physician order for dialysis three times a week, had no communication documented between the facility and the dialysis center for 12 scheduled dialysis appointments. The last recorded communication was dated over a month prior to the surveyor's review. The facility's policy requires reviewing communication documents for pertinent information post-dialysis, which was not adhered to in this case. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the issue, attributing it to the dialysis center's failure to return the communication binder. Despite attempts to retrieve the missing information via fax, the facility struggled to maintain up-to-date records. The surveyor highlighted the importance of timely communication as per the Center for Medicare/Medicaid Services memorandum, which emphasizes the need for collaboration between dialysis facilities and nursing homes to ensure effective and safe treatments. The deficiency was communicated to the DON and Nursing Home Administrator during an end-of-day meeting.
Deficiencies in Comprehensive Care Planning for Two Residents
Penalty
Summary
The facility failed to ensure that two residents, R82 and R31, had individualized comprehensive care plans addressing their specific needs. R82, who was admitted with multiple diagnoses including a fracture, Guillain-Barre syndrome, and diabetes, had a foley catheter inserted due to urinary retention. Despite this significant change in R82's condition, the facility did not develop a comprehensive care plan for the catheter management, as confirmed by the surveyor's review of R82's records and interviews with the Director of Nursing (DON). The DON acknowledged that the care plan should have been initiated when the catheter was inserted, but it was missed in the daily morning meetings where care plans are typically finalized. R31, another resident with diagnoses including metabolic encephalopathy and muscle weakness, was assessed as frequently incontinent of bowel and bladder. However, the care plan in place was not person-centered or comprehensive, as it inaccurately stated that R31 was not toileted, despite the resident's MDS indicating frequent incontinence. The surveyor's interview with R31 revealed that the resident received assistance when needed, contradicting the care plan's documentation. The DON initially believed the care plan was resolved because R31 was thought to be continent, but upon review, it was acknowledged that the care plan was incorrectly resolved. These deficiencies highlight the facility's failure to adhere to its policy of developing individualized, comprehensive care plans based on residents' assessments and needs. The lack of appropriate care plans for R82's catheter management and R31's incontinence care indicates a lapse in the facility's interdisciplinary team process and communication, as care plans were not updated or initiated in response to changes in the residents' conditions.
Failure to Verify G Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident receiving medications through a gastronomy (G) tube received care that met professional standards. On October 24, 2024, a surveyor observed a Licensed Practical Nurse (LPN) administering medications to a resident via a G tube without verifying the tube's placement beforehand. The facility's policy, revised on September 8, 2023, requires that the placement of the feeding tube be verified before administering medications, which includes checking the tube's external length and inspecting gastric aspirate. However, the LPN did not follow this procedure and proceeded to administer 15 crushed medications mixed with water without checking the tube's placement. The resident in question had a physician's order dated March 17, 2023, which mandated that the tube placement be checked before the initiation of formula, medication administration, and flushing, or at least every eight hours. During an interview with the Director of Nursing (DON), the surveyor explained the concern regarding the LPN's failure to check the G tube placement. The DON acknowledged the concern and confirmed that it is the facility's policy to verify tube placement prior to medication administration. No additional information was provided by the facility regarding this incident.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to ensure its medication error rates were not 5 percent or greater, resulting in a medication error rate of 41.67%. On October 24, 2024, a resident identified as R55 was administered 15 medications via a gastronomy (G) tube by an LPN. The LPN did not flush the G tube with water before or after administering the medications, which is a violation of the facility's policy. The facility's policy, revised on September 8, 2023, requires flushing the tube with 30 ml of water before and after medication administration. The physician's order allowed for combining medications during G tube administration with flushes as ordered. The Director of Nursing acknowledged the concern when interviewed by the surveyor, confirming that the facility's policy was not followed.
Failure to Administer Ordered Medications Upon Admission
Penalty
Summary
The facility failed to ensure that a resident received ordered medications upon admission, leading to unmet care and health needs. The resident, who had diagnoses including the presence of a right artificial knee joint, end-stage renal disease, and kidney transplant status, was admitted to the facility in the evening. However, several physician-ordered medications were not administered due to unavailability, and there was no evidence that the physician was notified about the unavailability of these medications. Specifically, Belsomra, Prednisone, Apixaban, and Calcium Acetate were not given as ordered on the evening of admission and the following day. The Director of Nursing (DON) confirmed that the medications were not administered and that there were no progress notes indicating that the physician was notified. Facility policy requires that medications be administered according to physician orders and that the physician be notified if medications are not available or not given. The failure to administer these medications and notify the physician was verified through record reviews, interviews, and facility policy review.
Failure to Administer Insulin Before Meals
Penalty
Summary
The facility failed to administer insulin to one resident in a timely manner, as per the physician's order. The resident's Medication Administration Record (MAR) indicated that insulin was to be administered before meals based on a sliding scale determined by the resident's blood sugar levels. However, the insulin was administered after meals on multiple occasions. The resident reported receiving her insulin injections late, both in the morning and at noon, which was confirmed by the Registered Nurse (RN) who administered the insulin. The RN admitted to delaying the insulin administration due to concerns about the resident not eating and other issues on the floor. The Director of Nursing (DON) confirmed that the insulin was administered after meals, contrary to the physician's orders. The facility's policy on administering medications, which requires adherence to the physician's written orders, was not followed. This failure to administer insulin before meals as ordered had the potential to result in unmet healthcare needs for the resident.
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Illustrative
What surveyors actually found near you
We read the 706 citations issued within 25 miles in the last 12 months — including the 19 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Milwaukee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saint Johns On The Lake | 0.3 mi | ★★★★★ | 1 | 0 |
| Milwaukee Catholic Home | 0.4 mi | ★★★★★ | 8 | 0 |
| Eastcastle Pl Bradford Ter Conv Ctr | 0.5 mi | ★★★★★ | 16 | 0 |
| Jewish Home And Care Center | 0.8 mi | ★★★★★ | 22 | 3 |
| Milwaukee Health And Rehab | 3.6 mi | ★★★★★ | 14 | 0 |
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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.