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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Florence Health Services during CMS and state inspections, most recent first.
Unqualified food and nutrition services director: The facility did not designate a qualified director for food and nutrition services. The AM who handled day-to-day kitchen and staff management stated he was not certified as a dietary manager, while the DM only oversaw the facility intermittently and held the food service manager certification. Records showed the AM had no certification, and no dietary waiver had been submitted or was in place.
Unsafe food storage and improper sanitizer testing were observed in the kitchen. Multiple dry, refrigerated, and frozen foods were open, unsealed, unlabeled, or undated, and several items were exposed to air. The 3-compartment sink had inconsistent sanitizer conditions, the testing log was incomplete, and a DA later measured the sanitizer at 500 PPM with water at 129.4 degrees F without documenting the result; the DM acknowledged the testing was not done correctly.
Missing Resident Rights and Complaint Posting Information: The facility did not have the required postings available for residents on how to file complaints with the State Survey Agency, how to file grievances, or how to access residents’ rights information. During a Resident Council meeting, several residents stated they did not know how to file a complaint or grievance and had no access to the required information. The NHA said the postings should have been on the wall near the nurses’ station and on the SSC’s door, but the surveyor could not find them, and the posted state agency map did not include contact information.
Unclean rooms, missing bariatric bedding, and staggered meal service affected several residents. Rooms and bathrooms had dirt, debris, dust, urine stains, and other unsanitary conditions, while a bariatric resident reported discomfort because staff used a flat sheet that did not fit the bed. In the dining room, residents at the same table were served at different times, leaving some to watch tablemates eat while they waited for their own meals.
Ordered Diets and Portion Sizes Not Followed: Surveyors found that multiple residents with pureed and mechanically altered diets did not receive ordered textures, serving sizes, or menu items at breakfast and lunch. A resident with dysphagia, dementia, and a guardian did not get ordered egg portions or a pureed roll, another resident did not receive ordered chopped meat or Boost, and others missed items such as cottage cheese, a bread slurry, and cookies. Kitchen observations showed staff portioning trays incorrectly, and the RD confirmed repeated texture and portion errors.
Food temperatures were not consistently taken or documented, and staff later filled in logs after the fact with guessed temperatures. Surveyors also observed altered-texture foods being prepared without standardized recipes, including slurried items made by pouring cold milk over food and pureed items made by estimating liquid amounts. During tray checks, several hot items were below the required temperature and cold beverages were above the safe range, and a resident with intact cognition reported meals were often delivered cold or lukewarm.
A facility failed to provide HS snacks in accordance with resident preferences and orders. Several residents said they were not offered bedtime snacks, and one resident with diabetes reported not receiving a diabetic HS snack. The RD stated HS snacks should be offered daily to all residents, including diabetic snack options for residents with diabetes, but nursing staff did not have access to snacks after the kitchen closed.
Infection surveillance and staff illness tracking were not maintained as required. The staff infection line list showed multiple staff with fever, vomiting, diarrhea, and respiratory symptoms, but their return-to-work records did not document when symptoms ended or when they were well enough to return. The IP stated the line lists were not completed by the IP, the DON said the IP should lead the process, and the NHA confirmed the dates and times of last symptoms and well dates were missing.
A resident with dementia and severely impaired cognition had a court-ordered guardian, but the facility did not obtain protective placement paperwork. The SSC was unaware the resident required protective placement, confirmed it was not in place, and did not know it was their responsibility or whom to contact to obtain it.
Failure to Report Allegation of Abuse/Neglect: A resident with a stage 4 pressure ulcer, other wounds, and moderate cognitive impairment reported that an RN repeatedly refused to cover or redress the buttock wound after stool incontinence, despite the resident’s requests to protect it from feces and infection. The resident told the DON and NHA about the incident, but the NHA acknowledged the allegation was not reported to the SA.
Incomplete Investigation of Abuse/Neglect Allegation Involving Wound Care: A resident with impaired cognition and multiple pressure injuries reported that an RN refused repeated requests to cover a buttock wound after episodes of diarrhea and stool incontinence. The resident said the concern was reported to the DON and NHA, but the grievance was not found in facility records and the investigation produced later was incomplete, lacking resident and staff interviews, documented follow-up with the resident, and broader nurse education on wound care and abuse/neglect reporting.
A resident with dementia and severely impaired cognition was involved in two resident-to-resident altercations, including pushing one resident in a wheelchair and later pushing another resident while expressing anger. Staff separated the residents and an RN assessed one resident for injury, with none noted. The resident’s care plan was not revised to include behavioral interventions after the incidents, and the NHA verified the omission.
A resident with severe cognitive impairment had an air mattress ordered to be set to the resident’s weight and checked each shift, but it was found at maximum firmness until an LPN corrected it. Another resident with a stage 4 buttock pressure ulcer and diarrhea reported that an RN refused to cover the wound despite repeated requests to keep it free from feces and infection; CNA-L also said the RN refused to dress the wound, and the wound care RN and DON later confirmed the wound should be covered and soiled dressings changed after bowel movements.
Failure to implement fall prevention interventions for a resident with dementia, Parkinson’s disease, impaired cognition, and multiple falls. Surveyors observed the resident in the dining room wearing grippy socks and no shoes despite a care plan intervention for shoes when in the dining room. A CNA said the shoes were not used because they did not fit properly and caused pain, and the DON confirmed the increased supervision intervention lacked measurable parameters and that the care plan interventions were not consistently implemented or reviewed.
Inconsistent urinary output monitoring after Foley catheter removal. A resident with obstructive uropathy and diabetes had a physician order to discontinue a Foley, monitor I&O, and reinsert the catheter if unable to void or if urinary output was low. Staff did not consistently document output after removal, and an LPN, DON, and VPS reviewed the record and could not determine whether the resident had low or decreased urine output based on the documentation.
A resident with OSA used a CPAP nightly, but staff did not clean the mask or tubing per policy or the manufacturer’s instructions, and the resident’s record did not contain an order for CPAP use. Surveyor observation and resident interview confirmed the mask remained unclean over multiple days, and the DON verified residents with CPAP machines should have orders for use and cleaning of the equipment.
Nurse staffing information was not posted daily or present at the start of shifts. Surveyors did not observe the required staffing posting during multiple facility tours, and the NHA stated the posting would be up shortly. The report cited required posting elements including RN, LPN, and CNA staffing, actual hours worked, and resident census.
The facility failed to maintain toilets in a clean and homelike condition when multiple shared-bathroom toilets contained rusty metal strips at the openings or under elevated seats, which several residents reported as bothersome. Residents stated they had informed CNAs, housekeeping, and maintenance about the rust, but these concerns were not reflected in maintenance request logs. A housekeeper acknowledged seeing the rust and hearing resident complaints, and an account manager admitted being aware of the condition but did not report it. An LPN, the DON, and the executive director all confirmed upon observation or interview that the rusty strips were inappropriate and not consistent with a safe, homelike environment.
A resident with vascular dementia, urinary tract issues, and an indwelling catheter experienced a change in condition, including confusion and milky, yellow urine. The care plan required staff to report and document such changes and possible UTI signs. Nursing notes recorded the abnormal urine and later an SBAR entry noted abnormal BP, increased confusion, and new orders for urinalysis/culture and increased fluids, with subsequent transfer to urgent care and hospital admission. However, the DON, who reported contacting a urology department and receiving instructions to send the resident to urgent care, did not document these provider notifications or related details in the medical record, resulting in incomplete documentation of the change in condition and provider communication.
Three residents experienced abuse due to the facility's failure to investigate and implement interventions after an initial altercation involving verbal and physical aggression. The care plan for the aggressive resident was not updated, and staff were unaware of the incident, leading to a subsequent physical assault on another resident. The residents involved had moderate cognitive impairment and other significant medical conditions.
A resident-to-resident altercation involving verbal and physical aggression was not reported to the State Agency as required by facility policy. Both residents involved had moderate cognitive impairment and significant medical histories. The DON was unaware of the full extent of the incident and confirmed that the required report was not made.
Two residents with moderate cognitive impairment were involved in a verbal and physical altercation, including yelling and the use of mobility aids in a confrontation. Despite facility policy requiring immediate investigation of abuse allegations, no thorough investigation was conducted, and the DON was unaware of the incident's extent.
A resident with a history of trauma and multiple chronic conditions did not have a care plan that included specific trauma-related diagnoses, triggers, or individualized interventions, despite assessments identifying these needs. Staff interviews revealed that team members were unaware of the resident's trauma history or how to respond to trauma-related events, and the care plan contained only generic statements. This lack of individualized planning resulted in staff being unprepared to address the resident's trauma needs, especially after a physical assault by another resident.
A resident with diabetes and multiple comorbidities was admitted with hospital discharge orders for scheduled and sliding scale insulin, as well as recommendations for close blood glucose monitoring. The facility failed to transcribe the sliding scale insulin order and did not implement frequent blood sugar checks, resulting in only once-daily monitoring and omission of the sliding scale regimen. Staff interviews revealed confusion about order transcription and monitoring frequency, and the pharmacy did not identify the missing order.
A medication cart containing drugs and biologicals was left unlocked and unattended by an LPN during medication administration, with multiple residents passing by the exposed drawers. Facility policy requires medication carts to be locked when not attended by authorized staff, and both the LPN and DON confirmed this standard was not followed.
A resident with intact cognition reported to staff that a CNA got in their face and refused to provide requested care, which the resident described as abuse. Although the incident was reported internally and to the State Agency, the facility did not notify local law enforcement as required by policy and federal regulations. The NHA was aware of the reporting requirements but did not report the allegation to law enforcement, relying instead on a later conversation with the resident.
A resident with severe cognitive impairment was reported by family to have missing cash from their wallet. The facility investigated by interviewing the resident and family, and searching the resident's room, but could not determine what happened to the money. Despite policy requirements, no staff education or preventative action was taken following the allegation of misappropriation.
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete documentation and delayed reporting of a COVID-19 outbreak. The Infection Preventionist's dual role as a floor nurse hindered proper management, leading to inconsistent symptom tracking for residents. Additionally, the facility did not implement Enhanced Barrier Precautions for residents with wounds or MDROs, further highlighting deficiencies in infection control practices.
The facility failed to ensure the Infection Preventionist (IP) dedicated sufficient part-time hours to manage the infection prevention and control program. An LPN, also working full-time as a floor nurse, was only able to allocate about 2 hours per week to IP duties, leading to an incomplete infection prevention program, as observed by surveyors.
The facility failed to store and prepare food in a sanitary manner, affecting most residents. Food items lacked proper labeling with open and use-by dates, and microwave heating procedures were not followed, as food was not covered or allowed to stand for the required time. Additionally, the temperature of sanitizing solutions was not tested, only the PPMs, contrary to instructions. The Dietary Manager and Registered Dietician acknowledged these oversights.
A resident was unnecessarily administered antibiotics due to the facility's failure to implement its antibiotic stewardship program. The resident was prescribed Bactrim DS for a UTI that did not meet infection criteria, and the culture showed resistance to the antibiotic. The physician was not informed of the culture results, leading to the completion of an ineffective seven-day course. The Infection Preventionist acknowledged the oversight, highlighting a lapse in communication and adherence to the facility's policy.
The facility failed to document the offer or administration of the 2024-2025 COVID-19 vaccine for three residents, as required by their policy. Despite previous declination forms, there was no record of the most recent vaccine offer or refusal, confirmed by the Infection Preventionist.
A resident with a history of stroke and other conditions was hospitalized with a head injury after a fall from a Hoyer lift. During a later hospitalization, hospital staff found a vaginal mucosa tear, leg bruises, and spinal fractures, which the facility failed to report to the State Agency. Interviews revealed staff were unsure about reporting requirements, and no investigation was conducted into the injuries.
A resident in a long-term care facility was hospitalized with a head injury after a fall and later found to have a vaginal mucosa tear, bruises, and compression fractures. The facility failed to investigate these injuries, despite being notified by hospital staff. Interviews with facility staff revealed a lack of awareness and action regarding the new injuries, and no investigation was conducted to determine their cause.
A facility failed to provide proper notification to a resident, their POA, and the Ombudsman regarding hospital transfers. The resident, with a history of stroke and other conditions, was transferred twice without receiving written notices. The DON signed notices on behalf of the resident and POA, but there was no documentation of mailing. Staff were unaware of notification requirements for ED transfers, leading to the deficiency.
A facility failed to provide a resident and their POA with written information about the bed hold policy during hospital transfers. The resident, who had a history of stroke and other medical conditions, was transferred twice without receiving the required notice. Staff were unfamiliar with the policy, and documentation was incomplete, leading to a deficiency in procedural compliance.
A resident's meal preference for French toast was not honored during lunch service, despite multiple requests from staff. The resident, who consistently preferred French toast due to feeling ill with other foods, left the dining area without eating. The facility's failure to update the meal ticket and lack of preparation knowledge contributed to the deficiency.
The facility failed to prepare pureed meals according to standardized recipes, using water instead of broth or gravy, which compromised the nutritional value for two residents. Additionally, one resident did not receive all items listed on their meal ticket, as a pureed cranberry muffin was omitted. These actions were contrary to the facility's dietary policies and procedures.
The facility did not ensure pneumococcal vaccinations were reviewed, offered, or administered to two residents as per CDC guidelines. The medical records lacked declination forms and documentation of vaccine discussions. The Infection Preventionist admitted to not having a system for pneumococcal vaccines, focusing more on COVID-19 and influenza vaccines.
A resident with a history of malignant neoplasm and dysphagia experienced low blood pressure, vomiting, and diarrhea. The facility failed to promptly notify the physician of these changes, despite policy requirements. The resident initially refused hospital transfer, and the physician was only contacted after the resident's daughter intervened. The physician was not informed of the vomiting and diarrhea until later in the day.
A resident undergoing chemotherapy for esophageal cancer did not have a comprehensive care plan addressing increased risks for infection, dehydration, or abnormal lab values. Despite facility policy requiring such plans, the care plan lacked necessary interventions and monitoring guidelines. The DON acknowledged the expectation for a care plan, highlighting a lapse in adherence to care planning processes.
A resident undergoing chemotherapy for esophageal cancer experienced low blood pressure, vomiting, and diarrhea, but the facility failed to conduct a comprehensive assessment of his condition. Despite the facility's policy requiring frequent monitoring, no formal hydration assessment was performed. The resident was eventually transferred to the hospital, where he expired the following day due to neutropenic sepsis.
Unqualified food and nutrition services director
Penalty
Summary
The facility did not designate a person to serve as the director of food and nutrition services who met the required qualifications of being a certified dietary manager, a certified food service manager, having national certification for food service management and safety from a national certifying body, or holding an associate's or higher degree in food service management or hospitality. During an initial kitchen tour, the Account Manager indicated that he was not certified as a dietary manager. The District Manager later stated that he oversaw several facilities, did not work at the facility regularly, and that the Account Manager handled the day-to-day kitchen and staff management. Record review showed the Nursing Home Administrator provided a Long Term Care Food Service Manager certification for the District Manager, but also provided a word document indicating the Account Manager had no certification. The District Manager stated he had taken over regional management in early March and tried to be at the facility once or twice weekly, but it was difficult because his assigned facilities were spread out. When the surveyor requested any dietary waivers in place, none were provided, and the Division of Quality Assurance Dietary Services Consultant confirmed the facility had not submitted a waiver for the dietary manager position. The DON stated the facility should have had a waiver in place until the Account Manager was certified.
Unsafe Food Storage and Improper Sanitizer Testing
Penalty
Summary
Food was not stored and served in a safe and sanitary manner. During an initial kitchen tour, the surveyor and the Account Manager observed multiple food storage problems in dry storage, coolers, and freezers. Items were found open, unsealed, unlabeled, or undated, including elbow pasta, potato chips, flour with a scoop left in it, cereal, Goldfish crackers, sausage links, Swiss cheese, cheese, butter, parmesan cheese with a hole in the package, onions, cottage cheese, tomato soup, and red Jell-O with fruit. In the freezer, several items were also open, unsealed, undated, and exposed to air, including folded cheese omelettes, hamburger patties, fried eggs, sugar cookie dough, cinnamon rolls, pizzas, donuts, French toast, and pancakes. The Account Manager stated food products should be sealed, labeled, and dated with open, made, and use-by dates, and that food past the use-by date should be discarded. The surveyor also observed concerns with the three-compartment sink and sanitizing solution. The first compartment contained water, dish soap, and dishes, the second contained water, and the third compartment was labeled sanitizer but did not contain any liquid at the time of the initial tour. Dishes and utensils were in the sink, and a sanitizer testing log was posted above it. The log did not identify the month, had entries only through the 20th, and every recorded PPM entry was 300. The Account Manager stated sanitizer testing and documentation should occur every shift, and the District Manager later identified the log as belonging to March 2026. On a later observation, the surveyor asked a Dietary Aide to test the sanitizing solution. The aide used a Hydrion test strip and read the solution at 500 PPM, but did not document the result. The aide then used a thermometer and measured the sanitizing solution at 129.4 degrees F. The aide stated the water should have been temped and was not aware the temperature was too high for an accurate PPM reading or that the PPM was outside the effective range. The District Manager acknowledged the sanitizer testing was not done correctly and stated that if the PPM are not appropriate, there is potential to not sanitize effectively and put residents at risk. The Registered Dietitian and Director of Nursing both stated kitchen staff should follow the facility's food storage, preparation, and serving policies.
Missing Resident Rights and Complaint Posting Information
Penalty
Summary
The facility did not ensure residents were given information in a format and language they could understand about how to file a complaint, including the name and contact information for the State Survey Agency and a list of names, addresses, and telephone numbers of other pertinent state agencies. The facility also did not ensure information about residents’ rights and how to file a grievance was posted in the building. During an environmental tour on 4/6/26, the surveyor could not locate the required postings on how to file a complaint with the State Agency, access a list of state agencies, file a grievance with the facility, or review residents’ rights. During a Resident Council meeting on 4/7/26, R39, R55, R18, R45, and R46 stated they did not know how to file a complaint with the State Agency, did not know how to access a list of state agencies, did not know how to file a grievance with the facility, and did not have access to information regarding residents’ rights. R39’s MDS dated 1/23/26 showed moderately impaired cognition, R18’s MDS dated 3/23/26 showed moderately impaired cognition, R45’s MDS dated 4/7/26 showed intact cognition, and R46’s MDS dated 4/13/26 showed intact cognition; R55’s record did not contain cognition information. The NHA stated the required postings were supposed to be on the wall across from the nurses’ station and on the SSC’s door, but the surveyor did not observe them there. The surveyor observed only an Ombudsman posting on the SSC’s door, and the SSC stated awareness of the required postings was lacking. On 4/8/26, the NHA said a map of state agencies was posted, but it did not include contact information, and the NHA could not locate the required postings containing State Agency contact information, grievance information, and residents’ rights.
Unclean Rooms, Missing Bariatric Bedding, and Staggered Meal Service
Penalty
Summary
The facility did not maintain a safe, clean, comfortable, and homelike environment for multiple residents. R4, R7, R23, and R43 were observed in rooms and bathrooms that were not clean and were not consistently cleaned daily. R4’s room contained dirt and debris on the floor and dust, hair, and garbage under the bed across multiple observations, and R4 stated housekeeping did not clean the room daily. R7’s room contained food debris, dust, hair, paper particles, and sticky spots on the floor, and R7 and a family member stated housekeeping did not clean daily. R23’s shared room had dust on the curtain and under the bed, along with a black sticky substance on the floor that remained present across repeated observations. The housekeeping manager stated rooms are cleaned daily and under-bed areas are included, but also acknowledged staffing limitations and verified the unkept and unsanitary conditions. R43’s room and bathroom were also observed in unclean and disorganized condition. R43 reported the room had not been cleaned recently and was difficult to keep organized. Surveyor observed garbage, open boxes, supplies on the sink, urine odor, dark material in the toilet, stains on the bathroom floor, and toilet paper rolls with hemorrhoid cream inside one roll. On a later observation, the toilet seat and riser had urine stains, the bathroom floor had garbage, debris, and brown smudges that appeared to be feces, and the sink contained hair. The housekeeping manager confirmed the bathroom was unclean and stated the toilet and sink had been wiped the day before, while the floor had not been cleaned and the bathroom should be cleaned daily. R16, who had a BMI of 70 or greater, a stage 4 pressure ulcer, open wounds, cellulitis, chronic pain syndrome, and diabetes with neuropathy, reported discomfort because the bed did not have a bariatric fitted sheet. R16 stated staff often used a flat sheet that did not stay in place, leaving bare skin stuck to the mattress and making turning difficult. Surveyor observed the bariatric mattress covered with a flat sheet that was bunched up or unsecured, and staff were unable to locate bariatric fitted sheets in multiple linen closets until the administrator found some. In the dining room, residents seated at the same table were not served together. Surveyor observed multiple tables where one resident received a meal and ate while tablemates waited, with delays ranging from several minutes to more than 20 minutes. One resident, R55, stated it was hard to watch others eat while waiting for food, and the DON stated residents at the same table should be served together.
Ordered Diets and Portion Sizes Were Not Followed
Penalty
Summary
The facility did not follow ordered diets, menu items, and portion sizes for multiple residents with modified texture diets and therapeutic diet orders. Surveyors found that residents with pureed diets and mechanically altered diets did not receive the ordered serving sizes for breakfast on 4/7/26 or breakfast and lunch on 4/8/26. Surveyors also found that parslied noodles ordered for lunch on 4/7/26 were not provided as ordered for residents on pureed and mechanically altered diets; mashed potatoes were served instead. Several individual residents were documented as not receiving ordered items. One resident with dysphagia, diabetes, severe cognitive impairment, and a guardian had a pureed diet with added protein items and did not receive a double portion of eggs for breakfast or a pureed dinner roll for lunch. Another resident with cancer, dementia, and a modified texture diet did not receive ground or chopped meat as ordered at lunch and breakfast, and did not receive Boost at lunch. A resident with a mechanically altered diet did not receive the ordered diet at lunch. Other residents did not receive ordered items such as a protein item at breakfast, a cookie at lunch, a half cup of cottage cheese, a white bread slurry, or a pureed dinner roll. One resident with a cardiac diet and double portions of vegetables and meat did not receive a protein item for breakfast or double portions of vegetables at lunch on multiple days. During kitchen observations, surveyors saw staff portioning breakfast and lunch trays incorrectly for residents on pureed and mechanically altered diets. The breakfast steam table was set up with scoops that resulted in two tablespoons of sausage, 2 ounces of eggs, and 4 ounces of oatmeal being served to residents whose diet cards called for different amounts, including larger portions for pureed eggs and specific scoop sizes for modified textures. At lunch, staff served pureed beef pot roast, wax beans, and mashed potatoes in amounts that did not match the ordered pureed or mechanically altered textures, and some residents did not receive ordered bread items, yogurt, Boost, cottage cheese, or other menu items. The registered dietitian confirmed that staff made mistakes with textures, that meal tickets contained physician-ordered diets and resident preferences, and that staff needed repeated retraining during meal times to ensure orders, meal tickets, and preferences were followed.
Food Temperatures Not Properly Taken or Documented; Pureed Foods Prepared Without Standardized Recipes
Penalty
Summary
The facility did not consistently obtain and document food temperatures to ensure meals were served at safe and palatable temperatures, and it did not ensure residents on pureed diets had meals prepared using methods that conserved nutritive value. The facility’s policies required food to be prepared by standardized recipes, served at safe temperatures, and transported and documented appropriately. During kitchen observation and record review, surveyors found that temperature logs for March and April 2026 were incomplete, with many meals lacking temperatures for hot foods, pureed foods, and beverages. The account manager acknowledged that it was not acceptable for staff not to take or document temperatures, but could not explain why the logs were incomplete. Surveyors later observed April temperature logs that had been filled in after the fact in the same handwriting and with the same pen. The district manager admitted creating the April logs the evening before and stated the temperatures were guessed rather than taken at the time of service. The district manager also recorded temperatures for pureed and mechanically altered foods using arrows instead of actual temperatures, then later wrote numerical temperatures over the arrows and stated the arrows were a mistake. Staff interviews showed confusion about who had taken temperatures, with the cook and account manager each stating the other had done so. Surveyors also observed breakfast service where food temperatures were not being taken or recorded while trays were being prepared and served. Surveyors observed altered-texture foods being prepared in ways that did not conserve nutritive value and did not follow recipes. A cook prepared slurried French toast and pancakes by pouring cold milk over the food, and the district manager stated staff should use hot liquids for slurried foods but had not educated staff on that practice. The cook and account manager also stated they did not follow recipes when preparing oatmeal or pureed foods and instead estimated amounts of water, syrup, or other liquids. The registered dietitian and director of nursing both stated staff should follow recipes and that hot foods should be served hot and cold foods and beverages cold. During tray observation, surveyors found multiple hot items below the required minimum temperature and cold beverages above the safe serving temperature. A resident with intact cognition reported that meals were often delivered cold or lukewarm and that staff seemed unable to provide hot food.
Failure to Provide HS Snacks as Requested and Ordered
Penalty
Summary
Meals and snacks were not served at times in accordance with resident needs, preferences, and requests for 6 of 7 sampled residents. During a Resident Council meeting, R39, R55, R18, R45, and R46 stated they were not offered a bedtime snack as preferred. The residents reported they received an afternoon snack between 3:00 PM and 3:30 PM but were not offered a snack at HS. R39 stated R39 was never offered an HS snack, and R45 stated R45 was not offered a snack in the afternoon or at HS, even though R45 wanted to be offered snacks each time they were available. Surveyor observation showed a snack cart in the 200 wing hallway with fruit, sandwiches, and crackers, and nursing staff were seen entering rooms and offering snacks to residents. Record review showed R39 had moderately impaired cognition, R18 had moderately impaired cognition, R45 had intact cognition, and R46 had intact cognition; R55's record did not contain cognition information. The Registered Dietitian stated HS snacks should be offered and provided to all residents daily, that some residents had specific HS snack orders, and that it was imperative residents with diabetes receive an HS snack to stabilize and manage blood sugar. The RD also stated the kitchen was locked after staff left for the day and nursing staff did not have access to snacks. For R43, who had diabetes with neuropathy, was receiving insulin glargine twice daily, and had blood sugars ranging from 90 mg/dL to 260 mg/dL over the prior 4 months, the record and interviews showed R43 did not receive a diabetic snack at HS and stated R43 was not getting diabetic snacks at night anymore.
Infection Surveillance and Staff Return-to-Work Documentation Not Maintained
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. During March 2026, the staff infection line list showed one staff member with a fever, one with vomiting, two with diarrhea, and two with vomiting and diarrhea, but the facility allowed staff to return to work without documenting when their symptoms resolved. The line list header included fields for date and time of last symptoms, well date, and return to work, and the form indicated the DON would complete those sections, but those entries were not completed for the affected staff. The facility’s Infection Surveillance policy stated that infection surveillance is a core activity of the infection prevention and control program and that employee infections, including influenza or gastrointestinal outbreaks, would be tracked as appropriate. Wisconsin DHS guidance for acute gastroenteritis outbreaks stated that staff should be excluded from resident care and food service duties at the onset of symptoms such as nausea, vomiting, abdominal pain, and/or diarrhea, and remain excluded until asymptomatic and free of diarrhea and vomiting for 48 hours. Wisconsin DHS respiratory illness guidance stated HCP with respiratory virus symptoms may return to work when at least three full days have passed since symptom onset, symptoms are improving, and the person has been fever-free for 24 hours without fever-reducing medications and feels well enough to work. Survey review of the March 2026 line list showed CNA-L had a fever on 3/1/26 and later had diarrhea, CNA-M had diarrhea, CNA-N had nausea, vomiting, and diarrhea, CNA-O had cough and vomiting, and RN-P had headache, vomiting, and diarrhea. Each returned to work without documentation of the date and time of last symptom, well date, or return-to-work date. The IP stated the staff infection line lists had not been completed by the IP and that the IP was still learning the role and also worked on the floor when needed. The DON stated the IP should take the lead on completing the line lists, and the NHA stated staff could not return to work until 24 hours after a fever resolved without medication, but was not sure when the listed staff returned to work and verified the dates and times of last symptoms and well dates were not documented.
Failure to Obtain Protective Placement for Resident With Guardian
Penalty
Summary
The facility did not ensure protective placement was obtained for 1 resident with a legal guardian. The resident was admitted on 1/30/26 and had a diagnosis of dementia, with an MDS dated 3/9/26 showing a BIMS score of 2 out of 15, indicating severely impaired cognition. The resident had a court-ordered guardian dated 2015, but the medical record did not contain protective placement paperwork. During interview on 4/7/26, the Social Services Coordinator stated they were not aware the resident required protective placement in the facility, confirmed the resident did not have protective placement, and did not know it was their responsibility to ensure protective placement was obtained or whom to contact to obtain it.
Failure to Report Allegation of Abuse/Neglect
Penalty
Summary
The facility failed to report an allegation of abuse/neglect to the State Agency for one resident, R5, after R5 reported that RN-T repeatedly refused to change R5’s wound dressing or cover a pressure injury on the buttocks after episodes of stool incontinence. R5 stated the wound was normally covered, but the bandage and wound became soiled with stool after each diarrhea episode, and R5 asked RN-T and CNAs to cover the wound to protect it from feces and possible infection. R5 reported that RN-T refused multiple times, telling R5 there was no sense covering it because it would become soiled again, and R5 became upset and tearful. R5 had diagnoses including a stage 4 pressure ulcer of the right buttock, local infection of the skin and subcutaneous tissue, a chronic ulcer of the right lower leg, a stage 2 pressure ulcer of the left heel, and anxiety. R5’s MDS showed a BIMS score of 11, indicating moderate cognitive impairment. The resident reported the concern to the DON and NHA, and the NHA acknowledged awareness of the incident and that the allegation was not reported to the SA. The DON confirmed dressings should be changed after bowel movements, the wound should be covered, physician orders should be followed, and potential abuse/neglect should be documented and reported to the SA.
Incomplete Investigation of Abuse/Neglect Allegation Involving Wound Care
Penalty
Summary
The facility did not thoroughly investigate an allegation of abuse/neglect involving a resident with moderately impaired cognition and multiple pressure injuries, including a stage 4 pressure ulcer on the right buttock, a stage 2 pressure ulcer on the left heel, and other chronic wounds. The resident reported that an RN refused multiple requests to cover the buttock wound after repeated episodes of diarrhea and stool incontinence, stating there was no sense in covering it because it would become soiled again. The resident said the concern was reported to the DON and NHA, but the resident did not receive follow-up, and the grievance was not found in the facility’s grievance records when reviewed by surveyors. When surveyors requested the investigation, the NHA initially could not locate it and later produced an incomplete file. The file contained a grievance form and limited documentation showing education to the RN about wound care and infection control, plus education to CNAs about scope of practice, but it did not include resident or staff interviews, documentation of communication and follow-up with the resident, education to all nurses regarding wound care and infection control, signed education from the RN, or education regarding recognizing and reporting abuse/neglect. The DON confirmed that a wound dressing should be changed after a resident is cleaned following a bowel movement and verified that the wound should be covered and physician orders followed.
Care Plan Not Revised After Resident-to-Resident Altercations
Penalty
Summary
The facility did not ensure R10’s care plan was revised after resident-to-resident altercations. R10 had a diagnosis of dementia with behavioral disturbance, and the MDS dated 1/20/26 showed a BIMS score of 5 out of 15, indicating severely impaired cognition. On 3/29/26, R10 was observed pushing one resident down the hallway in a wheelchair, and staff separated the residents and redirected R10. Later that same day, R10 was observed pushing a different resident in a wheelchair while stating, “I have had it,” and positioned the resident with the resident’s knees against the wall. An RN separated the residents and assessed the other resident for injuries, with none noted. The record review showed R10’s plan of care was not revised to include behavioral interventions after these incidents. The NHA verified that R10 was initially placed on 15-minute checks, but those checks were discontinued, and the NHA was not aware of any care plan revisions or interventions following the incidents. On 4/8/26, the NHA again verified that R10’s care plan was not revised after the 3/29/26 incidents.
Failure to Maintain Pressure Injury Prevention and Wound Coverage
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new ulcers from developing for two residents. One resident, who had cerebral palsy, quadriplegia, seizures, a gastrostomy, severe cognitive impairment, and a guardian for medical decisions, had a physician order for a specialty air mattress to be set to the resident’s weight and checked every shift. The resident’s care plan also directed staff to provide the air mattress at the resident’s weight and monitor its function each shift. During observation, the resident’s air mattress was found set at greater than 350, maximum firmness, and an LPN later verified the setting was incorrect and adjusted it to the resident’s weight of 101 pounds. A second resident was readmitted with diagnoses including a stage 4 pressure ulcer of the right buttock, local infection of the skin and subcutaneous tissue, chronic ulcer of the right lower leg, a stage 2 pressure ulcer of the left heel, MRSA, and anxiety. The resident’s care plan and treatment record directed wound care to the right ischial/buttock pressure ulcer with cleansing, dressings, and coverage of the wound. The resident reported that during multiple episodes of diarrhea and loose stools, the wound dressing became soiled and the resident repeatedly asked staff to cover the wound to keep it free from feces and potential infection. The resident and CNA-L stated RN-T refused to dress the wound, saying there was no sense covering it because the resident would soil it again. CNA-L also reported asking RN-T multiple times to cover the wound, but RN-T refused even after the resident stopped having loose stools. CNA-L eventually retrieved bandages and covered the wound, and the issue was reported to other staff. The WCRN and DON later confirmed the wound should be covered at all times and that soiled dressings should be changed after bowel movements, and the DON confirmed physician orders should be followed.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility did not ensure the resident environment remained as free of accident hazards as possible for R10, a resident with dementia with behavioral disturbance, Parkinson’s disease, difficulty walking, anxiety, pelvic muscle wasting, low back pain, and severely impaired cognition with a BIMS score of 5 out of 15. R10 had multiple falls in the facility, including falls on [DATE], 11/14/25, 11/15/25, 11/16/25, 11/26/25, 12/22/25, 1/4/26, 2/2/26, 2/3/26, and 2/5/26. R10’s care plan, initiated for fall risk related to Parkinson’s disease and dementia, included interventions for more frequent checks and for R10 to wear shoes when in the dining room. Survey observations showed R10 in the dining room for lunch and breakfast wearing grippy socks and no shoes. A CNA stated R10 always wears grippy socks when walking and does not usually fall, and explained that shoes were not put on because R10’s feet swell and the shoes do not fit properly and cause pain. The DON confirmed R10 should wear shoes when ambulating, was not aware the shoes did not fit properly, and confirmed increased supervision had been added after falls in November 2025. The DON also verified the increased supervision intervention did not have measurable parameters or documented time intervals, and confirmed the care plan interventions were not being implemented or reviewed to ensure they were appropriate and effective for R10.
Inconsistent urinary output monitoring after Foley catheter removal
Penalty
Summary
The facility did not ensure appropriate care and services were provided after a Foley catheter was removed for a resident with diagnoses including obstructive uropathy and diabetes. The resident’s physician ordered the catheter discontinued on 4/1/26, with input and output to be monitored and the Foley reinserted if the resident was unable to void or had low urinary output. The resident’s MDS assessment dated 3/16/26 showed a BIMS score of 15 out of 15, indicating intact cognition. After catheter removal, urinary output was documented each shift through 4/1/26, but there was no output documented on 4/2/26. Output was then documented on 4/3/26 as 400 ml and 600 ml, on 4/4/26 as 300 ml, and there was no output documented on 4/5/26 or 4/6/26. During interviews, an LPN reviewed the record and verified staff had not consistently documented output, stating there should have been a hat in the toilet to collect urine and that incontinence frequency and saturation should have been documented. The LPN, DON, and VPS all reviewed the record and could not determine whether the resident had low or decreased urinary output based on the documentation, and the VPS stated the resident voided independently at times and that the output was not accurately documented.
Unclean CPAP Equipment and Missing CPAP Order
Penalty
Summary
The facility did not provide necessary respiratory care and services for a resident with obstructive sleep apnea who used a CPAP machine nightly. The resident also had diagnoses including hypertensive heart disease with heart failure, dysphagia, and pneumonia in 2/2026. The resident’s MDS assessment showed intact cognition with a BIMS score of 15 out of 15. The care plan identified sleep cycle issues related to obstructive sleep apnea and included CPAP use at bedtime and off in the morning, but it did not contain an order or instructions for cleaning the CPAP machine or its parts. Surveyor observation and resident interview showed the CPAP mask was unclean and had not been cleaned since the resident’s admission in January 2026. The resident stated staff did not assist with cleaning and that the mask and tubing had not been cleaned. The surveyor observed the same unclean condition on subsequent visits. The medical record did not contain an order for CPAP use, and the DON stated prior to the surveyor’s request, she was not aware the resident did not have a CPAP order and verified that residents with CPAP machines should have orders for use and cleaning of the machine and/or its parts.
Nurse Staffing Posting Not Displayed Daily
Penalty
Summary
The facility did not ensure nurse staffing information was posted daily and available at the start of each shift. Based on observation and staff interview, the required staffing posting was not present in the facility on 4/6/26 or on 4/7/26 prior to the start of the AM shift. The deficiency had the potential to affect all 49 residents residing in the facility. Survey observations on 4/6/26 at 9:24 AM, 10:31 AM, and 2:00 PM did not identify a nurse staffing posting in the facility. On 4/7/26 at 6:45 AM and 8:10 AM, the surveyor again did not observe a nurse staffing posting. At 8:11 AM on 4/7/26, the NHA stated that the nurse staffing posting had been learned and would be posted shortly, and verified employment as NHA since 4/2/25. The report also cited DQA memo 12-020, which requires daily posting of staffing information including facility name, current date, staffing numbers by RN, LPN, and CNA, actual hours worked, and resident census.
Failure to Maintain Clean and Homelike Toilet Conditions
Penalty
Summary
The deficiency involves the facility’s failure to maintain residents’ toilets in a clean, safe, and homelike condition as required by its Safe and Homelike Environment Policy. Surveyors observed rusty metal strips at the openings of toilets in the shared bathrooms of four residents. One resident’s toilet had a rusty metal strip at the opening, and the resident reported that it bothered them and that they had informed a CNA and a housekeeper. Another resident was seen exiting a bathroom where the toilet also had a rusty metal strip; this resident stated they did not like the strip and had told staff about it previously. A third resident’s toilet had an elevated seat resting on a rusty metal strip, and this resident stated the strip bothered them and that they had reported it to maintenance a long time ago. A fourth resident’s shared bathroom toilet also contained a rusty metal strip at the opening. Staff interviews and record review showed that these concerns were not acted upon or documented through the facility’s maintenance systems. An LPN initially stated she had not seen rusty metal strips on toilets but, upon observation, acknowledged the condition was not acceptable. A housekeeper reported having noticed a rusty metal strip and said he had placed it on a maintenance clipboard at one time and confirmed residents had complained, noting the rust resembled feces. However, maintenance request logs from several months contained no entries about rusty metal toilet strips. The account manager supervising housekeeping admitted awareness of the rusty strips and acknowledged they were not homelike but had not reported them. The DON stated the strips were attached to toilet handrails and that housekeeping should have reported resident complaints or entered them into the computerized maintenance program, confirming they were not on the maintenance log and that toilets should not contain rusty metal strips. The executive director stated the strips had been present for a long time, were not appropriate, and that she had not been notified of resident complaints.
Failure to Document Provider Communication During Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete medical records and document provider communication during a resident’s change in condition, as required by its Change in Condition of the Resident policy. That policy specifies that documentation must include a description of the change, assessment findings, emergency care provided, provider notification with date, time, conveyed information, and orders received, responsible party notification, and names and titles of employees involved. The resident at issue had vascular dementia, a history of UTI, obstructive and reflux uropathy, benign prostatic hypertrophy with lower urinary tract symptoms, and an indwelling urinary catheter. The resident’s care plan directed staff to report changes in urine amount, color, or odor, and to report signs of UTI such as blood, cloudy urine, fever, increased restlessness, lethargy, or pain/burning to the physician. On the date in question, a nursing progress note recorded that the resident was in the hall with a walker, believed it was time for breakfast, was reoriented and assisted back to bed, and that the indwelling catheter was draining milky, yellow urine. Later that day, an eINTERACT SBAR note documented abnormal blood pressure and increased confusion, and that the provider ordered a urinalysis/culture and increased oral fluids. A physician discharge summary indicated the medical director and family were aware of orders to send the resident to urgent care, from which the resident was admitted to the hospital. The DON reported she was notified of the resident’s condition early that morning, called the urology department to seek an appointment, and later received instructions to send the resident to urgent care, but acknowledged she did not document in a progress note that she notified the physician or the urology department, despite the policy requirement. The ED also stated the resident’s change in condition should have been documented earlier in the day, demonstrating incomplete documentation of the change in condition and related provider communication.
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident altercations, for three of five sampled residents. On 9/11/25, an altercation occurred between two residents involving verbal and physical aggression, including yelling, swearing, threats, and physical contact with mobility devices. The care plan for the resident identified as the initial aggressor did not include goals, triggers, or interventions related to aggressive behavior, and the incident was neither investigated nor reported to the State Agency as required by facility policy. Following this, on 9/13/25, the same resident entered another resident's room and physically assaulted them by slapping them multiple times. This second incident was investigated and reported, but the lack of intervention after the first altercation was noted as a missed opportunity to prevent further abuse. Interviews with facility staff, including the Unit Manager and Director of Nursing, revealed that they were unaware of the initial incident and acknowledged that it should have been investigated and addressed per policy. The residents involved had significant medical and cognitive conditions, including dementia with behavioral disturbance, cerebral infarction, and other chronic illnesses. Both the Unit Manager and Director of Nursing confirmed that the care plan for the aggressive resident should have been updated immediately after the first incident, and that the failure to do so left other residents unprotected from further aggression.
Failure to Report Resident-to-Resident Altercation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the State Agency as required by its own policy and federal regulations. An altercation occurred between two residents, both with moderate cognitive impairment and significant medical histories, which involved verbal and physical aggression, including yelling, swearing, threatening, and pushing mobility devices against each other. The incident was documented in the medical record, and one resident was subsequently moved out of the shared room. However, the Director of Nursing was not aware of the full extent of the altercation and confirmed that the incident was not reported to the State Agency. The facility's policy mandates that all allegations of abuse, neglect, or exploitation be reported to the State Agency and other authorities within specified timeframes, depending on the severity of the incident. Despite this, the altercation between the two residents was not reported, and there was no evidence of a report being made when requested by the surveyor. Interviews with both residents confirmed the occurrence of the altercation, and the Director of Nursing acknowledged the reporting failure during the survey.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
A resident-to-resident altercation occurred between two residents, both with moderate cognitive impairment and significant medical histories, including dementia and cerebral infarction. The incident involved verbal and physical aggression, with yelling, swearing, and the use of mobility aids in a physical confrontation. Documentation in the medical record described the altercation, and interviews with both residents confirmed the occurrence, with one resident recalling the argument and physical contact, and the other unable to recall the event. Despite the facility's policy requiring immediate investigation of any alleged abuse, neglect, or exploitation, there was no evidence that a thorough investigation was conducted following the altercation. The Director of Nursing was unaware of the full extent of the incident and confirmed that no investigation had been initiated. This failure to investigate was in direct violation of the facility's own policies and procedures regarding the handling of abuse allegations.
Failure to Develop and Implement Individualized Trauma-Informed Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement an individualized, comprehensive, resident-centered care plan for a resident identified as having trauma. The resident had a history of chronic medical conditions, including COPD, alcoholic polyneuropathy, alcoholic cirrhosis with ascites, type 2 diabetes, and respiratory failure with hypoxia. Despite quarterly assessments indicating the resident experienced trauma related to life-threatening illness and exposure to combat and captivity, the resident's diagnoses list did not include a trauma-related diagnosis, and the care plan lacked resident-specific trauma interventions. The care plan in place contained general statements and non-specific interventions, such as determining triggers and de-escalation preferences, providing a safe environment, and referring to psychology as indicated. However, it did not specify the resident's actual trauma triggers or preferred interventions, even though the resident had communicated these during assessments. Staff interviews revealed that multiple team members, including RNs, CNAs, the DON, the Unit Manager, the MDS Coordinator, and the Social Services Coordinator, were unaware of the resident's trauma history, triggers, or specific interventions. Staff consistently stated that care plans should be personalized and include specific triggers and interventions to guide care, but this was not done for the resident in question. An incident occurred in which the resident was physically assaulted by another resident, resulting in significant distress and ongoing upset for the affected resident. Staff were not aware of how to respond to the resident's trauma or triggers following the incident, as the care plan did not provide the necessary individualized information. The Social Services Coordinator, who had signed off on the trauma assessments, acknowledged that the care plan should have been edited to include the resident's specific trauma and triggers but had not done so. This lack of individualized planning and communication led to staff being unprepared to meet the resident's trauma-related needs.
Failure to Transcribe and Implement Sliding Scale Insulin Order for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services to ensure the accurate administration of medication for a resident with multiple complex diagnoses, including type 2 diabetes, coronary artery disease, hypertension, COPD, diabetic foot ulcers with gangrene, cellulitis, and sepsis status post below-knee amputation. Upon admission from the hospital, the resident's discharge summary included orders for scheduled insulin (Lantus and lispro) and a sliding scale insulin regimen, along with a recommendation to monitor blood sugars closely. However, the sliding scale insulin order and the recommendation for frequent blood glucose monitoring were not transcribed into the resident's Medication Administration Record (MAR), and only once-daily blood glucose checks were ordered and performed. Staff interviews and record reviews revealed that the facility's process for transcribing hospital discharge orders was not followed thoroughly. The Director of Nursing (DON) and nursing staff indicated that orders are transcribed from the discharge summary and reviewed by the provider and pharmacy, but the sliding scale insulin order was omitted. Nursing staff were unaware that the sliding scale order was missing, and there was confusion regarding the frequency of blood glucose monitoring. The facility's policies required verification and clarification of transfer orders, but this was not done for the sliding scale insulin order. Further, the pharmacy did not identify the missing sliding scale order during their review, as they only check for discrepancies if a medication appears to be off. The DON acknowledged that the sliding scale should have been clarified and included in the orders, and that there was no process in place for a second nurse to double-check the transcription of admission orders. As a result, the resident did not receive blood glucose monitoring or insulin administration according to the hospital discharge instructions.
Medication Cart Left Unlocked and Unattended During Medication Pass
Penalty
Summary
A deficiency occurred when a medication cart was left unlocked and unattended by an LPN during medication administration on multiple occasions. The medication cart, which contained drugs and biologicals, was observed by a surveyor to be left open and unattended in the 200 wing and outside the dining room, with the drawers facing the hallway and exposed during the medication pass. Multiple residents were observed walking or wheeling past the unattended cart, increasing the risk of unauthorized access. The facility's policy, dated January 2023, requires that medication carts remain locked when not in use or when not attended by authorized personnel. During interviews, the LPN acknowledged that the cart should not have been left unlocked and stated that it was usually locked but was forgotten on these occasions. The DON also confirmed that medication carts are required to be locked when unattended.
Failure to Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically in relation to an allegation of abuse made by a resident. A resident with intact cognition and responsible for their own healthcare decisions reported to staff that a Certified Nursing Assistant (CNA) got in their face and refused to wash them when requested, which the resident identified as abuse. The incident was reported internally and to the State Agency, and the CNA was suspended pending investigation. However, the facility did not notify local law enforcement of the allegation as required by their policy and federal regulations. Interviews and record reviews confirmed that the Nursing Home Administrator (NHA) was aware of the reporting requirements and the two-hour timeframe for reporting allegations involving abuse, but chose not to notify law enforcement. The NHA based this decision on a subsequent interview with the resident, during which the resident reportedly no longer felt the incident was abuse. Despite this, the initial allegation was not reported to law enforcement as required, and the NHA was uncertain about the resident's feelings at the time the incident was first reported.
Failure to Implement Preventative Action After Alleged Misappropriation
Penalty
Summary
The facility failed to ensure preventative action was taken following an allegation of misappropriation of a resident's property. A resident with severe cognitive impairment and multiple medical diagnoses was reported by family members to have missing cash from their wallet. The family regularly counted the resident's money and noticed that two $50 bills were missing over a two-day period. The incident was reported to facility administration, and both the resident and family members were interviewed. The facility searched the resident's room but was unable to locate the missing money. There was disagreement among family members regarding whether the resident may have hidden the money, but no resolution was reached regarding the missing funds. Despite the facility's policy requiring analysis of such occurrences and implementation of preventative measures, including staff education, no staff education related to misappropriation was completed following the incident. The Nursing Home Administrator was unsure if staff education had been provided, and the Director of Nursing confirmed that it had not. The facility did not take further preventative action to address the potential for misappropriation or to prevent recurrence, as required by their own policies.
Inadequate Infection Control and Reporting in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which was evident during a COVID-19 outbreak in September 2024. The facility's documentation was incomplete, lacking necessary details such as symptom tracking, testing, and outbreak response. The Infection Preventionist (IP) was also working as a floor nurse, which limited their ability to manage the infection control program effectively. This resulted in incomplete surveillance documents and inconsistent symptom documentation for five residents who tested positive for COVID-19. The facility did not report the COVID-19 outbreak to the local health department in a timely manner, as required by state regulations. The first staff member tested positive on September 4, 2024, and the first resident on September 5, 2024, but the outbreak was not reported until September 11, 2024. Additionally, the facility experienced an RSV outbreak in March 2024, which was also reported late to the health department. The facility's failure to report these outbreaks promptly was a significant deficiency in their infection control practices. Furthermore, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with wounds or multidrug-resistant organisms (MDROs) as required. One resident with a diabetic ulcer did not have an EBP order or care plan, and another resident with an MDRO had an EBP order but was not placed on EBP. These oversights indicate a lack of adherence to infection control policies and procedures, contributing to the overall deficiency in the facility's infection prevention and control program.
Inadequate Time Allocation for Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) dedicated sufficient part-time hours to effectively manage the infection prevention and control program. The Licensed Practical Nurse (LPN) assigned as the IP was also working full-time as a floor nurse, which limited their ability to allocate adequate time to the infection prevention and control responsibilities. The facility's policy required the IP to be employed at least part-time, with hours varying based on the facility's needs, but the LPN was only able to dedicate approximately 2 hours per week to these duties. This was confirmed during an interview with the LPN, who expressed that the time allocated was insufficient for the role's responsibilities. The survey team observed that the facility's infection prevention and control program was not comprehensive, as evidenced by incomplete line lists, lack of symptom tracking, insufficient follow-through on vaccinations, and an incomplete antibiotic stewardship program. These deficiencies were noted during the survey conducted from November 11 to November 13, 2024. The Director of Nursing and the Administrator in Training were present during the interview with the LPN and did not dispute the LPN's statements regarding the inadequate time dedicated to infection prevention and control duties.
Deficiencies in Food Storage, Preparation, and Sanitization Procedures
Penalty
Summary
The facility failed to ensure food was stored and prepared in a sanitary manner, potentially affecting 50 of 53 residents. During a kitchen tour, surveyors observed several food items in the walk-in cooler and dry storage area that were not properly labeled with open or use-by dates, contrary to the facility's policy and the FDA Food Code. Items such as tomato juice, English muffins, bagels, salt, powdered sugar, flour, and sugar were found with only received dates, lacking the necessary open and use-by dates. The Dietary Manager (DM) acknowledged the oversight and admitted to dating errors due to haste. Additionally, the facility did not adhere to safe microwave heating procedures. The Registered Dietician (RD) and DM were observed reheating food in the microwave without covering it, failing to allow the required two-minute standing time for thermal equalization, and not stirring the food to ensure even heating. The RD and DM both acknowledged that the food should have been prepped ahead of time and at serving temperature on the steam table, but did not provide a reason for not observing the two-minute wait time. The facility also failed to test the temperature of sanitizing solutions as required. Although the parts per million (PPM) of the sanitizing solution were recorded, the water temperature was not tested or recorded, as indicated by the crossed-out temperature column on the logs. The DM confirmed that only the PPMs were tested, not the temperature, which is contrary to the manufacturer's instructions for the sanitizing solution. The Nursing Home Administrator expected staff to follow the facility's kitchen policies and procedures, which were not adhered to in this instance.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, resulting in the unnecessary administration of antibiotics to a resident. The resident, identified as R261, was transferred to the hospital and prescribed Bactrim DS for a urinary tract infection (UTI) that did not meet the facility's criteria for infection. Despite the urinalysis culture indicating resistance to Bactrim DS, the resident completed a seven-day course of the antibiotic without the physician being informed of the culture results. This oversight occurred because the facility's policy for monitoring and updating antibiotic use was not followed. The Infection Preventionist (IP) acknowledged that the physician should have been notified about the culture results, which showed resistance to the prescribed antibiotic. The facility's policy required nurses to communicate lab updates, but this was not done in R261's case. The IP also indicated that the process for coordinating antibiotic stewardship activities involved checking a folder in the Director of Nursing's office or the facility's medical record system, which was not adequately followed. This lack of communication and adherence to the antibiotic stewardship program led to the inappropriate use of antibiotics for R261.
Failure to Document COVID-19 Vaccine Offer and Status
Penalty
Summary
The facility failed to ensure that three residents, identified as R8, R11, and R29, were offered or received the 2024-2025 COVID-19 vaccine. The facility's policy mandates that residents and staff be educated and offered the COVID-19 vaccine, with proper documentation maintained in their medical records. However, upon review, the medical records of R8, R11, and R29 did not indicate whether they received, were offered, or declined the most recent COVID-19 vaccine. This lack of documentation is contrary to the facility's policy, which requires that each resident's medical record include documentation of vaccine education, administration, or declination. The surveyor's review of the medical records revealed that R8 had a declination form dated April 2020, R11 had one from April 2021, and R29 had one from August 2023. Despite these previous declinations, there was no documentation regarding the 2024-2025 COVID-19 vaccine. The Infection Preventionist confirmed the absence of documentation for these residents, indicating a failure in the facility's process to ensure compliance with their vaccination policy.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for a resident, identified as R15, to the Nursing Home Administrator (NHA) and the State Agency (SA). R15, who had a history of stroke, hemiplegia, hemiparesis, dysphagia, aphasia, gastrostomy status, and osteoarthritis, was transferred to the hospital with a head injury following a fall from a Hoyer lift. During a subsequent hospitalization for aspiration pneumonia, hospital staff discovered a vaginal mucosa tear with dried blood, bruises on the legs, and compression fractures in the thoracic and lumbar spine, none of which were reported by the facility to the SA. The facility's policy on abuse, neglect, and exploitation requires reporting of all alleged violations to the appropriate authorities within specified timeframes. However, the Director of Nursing (DON) indicated that the compression fractures were not reported because the discharge summary did not specifically mention them. The DON acknowledged that an investigation should have been initiated to determine the cause of the fractures and other injuries. Despite being informed by hospital staff about the vaginal tear, the facility did not document or report the injury, and there was no follow-up investigation. Interviews with facility staff revealed a lack of awareness and understanding of the reporting requirements. The DON and Administrator in Training (AIT) were unsure about the suspicion of abuse regarding the fractures, and the Social Worker (SW) failed to document a phone conversation with hospital staff about the vaginal tear. The facility's regional consultant suggested possible causes for the tear but did not confirm any investigation into these possibilities. The NHA did not provide a clear response when asked if the injuries should have been reported to the SA, indicating a gap in the facility's compliance with reporting protocols.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for a resident, identified as R15, who was part of a sample of six residents. R15 was transferred to the hospital with a head injury following a fall from a Hoyer lift and was later hospitalized for aspiration pneumonia. During the hospital stay, R15 was found to have a vaginal mucosa tear with dried blood, bruises on the legs, and compression fractures in the mid and lower back, none of which were investigated by the facility upon R15's return. The facility's policy on abuse, neglect, and exploitation requires immediate investigation of any allegations or suspicions of abuse, neglect, or exploitation. However, the Director of Nursing (DON) acknowledged that the facility did not investigate the compression fractures or the vaginal mucosa tear, despite being notified by hospital staff. The DON admitted that the hospital discharge summary should have prompted an investigation, and the Social Worker (SW) confirmed receiving a call from the hospital about the vaginal tear but failed to document or report it to the nursing staff. Interviews with facility staff, including the Nursing Home Administrator (NHA), DON, and Administrator in Training (AIT), revealed a lack of awareness and action regarding the new injuries discovered after R15's fall. The facility did not conduct interviews with R15 about the injuries, and there was confusion about the responsibility for investigating injuries that may have occurred at the hospital. The regional consultant suggested possible causes for the vaginal tear but confirmed that no investigation was conducted to determine the cause of the injuries.
Failure to Provide Proper Transfer Notification
Penalty
Summary
The facility failed to provide proper notification to a resident, their Power of Attorney (POA), and the State Long-Term Care Ombudsman regarding the resident's transfers to the hospital. The resident, who had a history of stroke, hemiplegia, hemiparesis, dysphagia, aphasia, gastrostomy status, and osteoarthritis, was transferred to the hospital on two occasions. On both occasions, neither the resident nor the POA received a written transfer notice, and the Ombudsman was not notified of one of the transfers. The facility's policy required that transfer notices be provided as soon as practicable and that the Ombudsman be notified via a monthly list. During the survey, it was found that the Director of Nursing (DON) signed the transfer notices on behalf of the resident and POA, indicating phone notification, but there was no documentation of the notices being mailed. A handwritten note suggested that the notice was mailed, but it was not returned. Additionally, the Business Office Manager and Social Worker were unaware of the requirement to provide written notices and notify the Ombudsman for transfers to the Emergency Department (ED) when the resident was not admitted to the hospital. This lack of awareness and documentation led to the deficiency in ensuring proper notification for the resident's transfers.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a resident, identified as R15, and their Power of Attorney (POA) with written information regarding the bed hold policy during two hospital transfers. R15 was transferred to the hospital on two occasions, once after a fall from a Hoyer lift resulting in a head injury and another time due to aspiration pneumonia. Despite these transfers, neither R15 nor their POA received a written notice of the bed hold policy, which includes the duration of the bed hold, the reserve bed payment policy, and the right to return to the facility. The facility's policy requires that such notice be provided at the time of transfer or within 24 hours, but this was not adhered to in R15's case. The surveyor's investigation revealed that the facility's staff, including an LPN and the Business Office Manager, were not familiar with the bed hold policy or the process for providing the notice. The Director of Nursing acknowledged that the forms were not signed by R15's POA and there was no documentation to confirm that the notices were mailed. Additionally, the bed hold forms lacked effective dates and daily rates, further indicating a lapse in the facility's adherence to its own policies. This deficiency highlights a failure in communication and procedural compliance regarding the bed hold policy for hospitalized residents.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to meet the nutritional needs of a resident, identified as R31, by not honoring their meal preferences during a lunch service. The facility's Meal Distribution and Dining and Food Preferences documents outline the procedures for meal assembly and honoring resident preferences, but these were not followed. During the lunch meal, the Dietary Manager (DM-G) and Registered Dietician (RD-H) were responsible for meal preparation. Despite multiple requests from kitchen staff (CK-I) to prepare French toast for R31, RD-H did not fulfill the request, citing a lack of knowledge on how to make the egg batter recipe. Consequently, R31 did not receive their preferred meal and left the dining area without eating. Interviews with staff and the resident revealed that R31 had a consistent preference for French toast at every meal due to feeling ill with other foods. The Dietary Manager acknowledged awareness of R31's preference and admitted that the meal ticket should have been updated to reflect this. The Registered Dietician later discussed meal preferences and nutrition with R31, who confirmed the desire to continue having French toast for every meal. The failure to provide the requested meal led to R31 leaving the dining room hungry, highlighting a lapse in the facility's adherence to its own policies regarding resident meal preferences.
Failure to Follow Dietary Procedures for Pureed Meals
Penalty
Summary
The facility failed to ensure that meals were prepared in a manner that conserved the nutritive value for two residents on pureed diets. The kitchen staff did not follow standardized recipes when preparing pureed food items, which is necessary to maintain the nutritional content of the meals. Specifically, during a lunch service, the Dietary Manager (DM) was observed using water instead of broth or gravy to puree meatloaf and green beans, which diluted the nutritional value of the food. This action was contrary to the facility's contracted food service's policy and the guidelines outlined in the position description for the Cook. Additionally, the facility did not provide all the items listed on a resident's meal ticket. One resident, who was on a regular diet with pureed texture and nectar consistency liquids, did not receive a pureed cranberry muffin as indicated on their meal ticket. The Dietary Manager acknowledged the oversight, stating that the muffin was already pureed and available but was not included with the resident's meal due to nervousness. These deficiencies were confirmed through staff interviews and record reviews, highlighting a failure to adhere to established dietary procedures and policies.
Failure to Administer Pneumococcal Vaccines to Residents
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were reviewed, offered, or administered to two residents, R29 and R48, as per CDC guidelines. The surveyor found that R29 and R48's medical records did not contain declination forms for pneumococcal vaccines in 2024, nor were there progress notes indicating that the risks and benefits of the vaccines were discussed with them. According to CDC recommendations, R29 should have been given one dose of PCV15, PCV20, or PCV21, and R48 should have received a dose of PCV15, PCV20, or PCV21 at least one year after their last PPSV23 dose, which was administered in 2000. The Infection Preventionist (IP)-F acknowledged the lack of a system in place for pneumococcal vaccines, as the focus was more on COVID-19 and influenza vaccines. IP-F indicated that the facility's Social Worker is responsible for obtaining vaccine declination forms upon admission, but there was no declination form for R48. IP-F also mentioned that if they become aware of a resident needing a pneumococcal vaccine, they contact the pharmacist to verify which vaccine should be administered and then ask the resident if they want the vaccine.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to promptly notify and consult with a resident's physician when there was a deterioration in the resident's clinical condition. The resident, who had been admitted with diagnoses including malignant neoplasm of the esophagus and dysphagia, experienced symptoms of low blood pressure and weakness. Despite these symptoms, the physician was not consulted immediately. The resident's condition included vomiting and diarrhea, which began in the afternoon and continued until the resident was transferred to the emergency room in the evening. The facility's policy required immediate notification of the physician for any significant change in a resident's condition, especially if the symptoms were acute or marked a significant change from usual symptoms. On the morning of the incident, the Director of Nursing was informed of the resident's low blood pressure and reviewed the nurse's notes. Although the physician was contacted about the low blood pressure, this consultation was not documented in the resident's medical record. The resident initially refused to go to the hospital, and the physician was not consulted again until the resident agreed to be transferred later in the day. The nursing staff did not consult the physician after the onset of vomiting and diarrhea, which were new symptoms for the resident. The Licensed Practical Nurse on the afternoon shift reported that the resident had multiple episodes of vomiting and diarrhea but did not contact the physician until the resident's daughter convinced him to go to the hospital. The physician confirmed that he was not informed of the vomiting and diarrhea until the evening, indicating a lapse in communication and adherence to the facility's policy for notifying physicians of significant changes in a resident's condition.
Failure to Develop Comprehensive Care Plan for Chemotherapy Patient
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who was admitted with a diagnosis of malignant neoplasm of the esophagus and was undergoing chemotherapy treatment. The care plan did not address the resident's increased risk for infection, risk for dehydration, or abnormal lab values, which required increased monitoring due to the chemotherapy treatments. This deficiency was identified during a review of the resident's records, which showed multiple abnormal lab values and ongoing chemotherapy treatment without a corresponding care plan to guide staff in monitoring and managing these risks. The facility's policy on comprehensive care plans, revised on 9/23/2022, mandates the development of a care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. Despite this policy, the care plan for the resident in question did not include necessary interventions or monitoring guidelines related to the resident's cancer diagnosis and chemotherapy treatment. The Nursing Home Administrator in training, who was also the Director of Nursing, acknowledged the expectation for such a care plan to be in place, indicating a lapse in adherence to the facility's care planning process.
Failure to Assess Change in Condition
Penalty
Summary
The facility failed to comprehensively assess a resident's medical status following a change in clinical condition. The resident, who had a history of esophageal cancer and was undergoing chemotherapy, presented with symptoms of low blood pressure and weakness. Despite these symptoms, a comprehensive nursing assessment was not conducted from the morning until the resident's transfer to the hospital in the evening. The facility's policy required frequent monitoring and assessment of the resident's condition, which was not adhered to. The resident experienced new symptoms of vomiting and diarrhea during the afternoon shift, yet no comprehensive assessment of hydration status or other vital signs was performed. The nursing staff did not conduct a Dehydration Risk Screener or any other formal assessment to evaluate the resident's condition, despite the facility's policy and the resident's deteriorating state. The resident's daughter eventually convinced him to agree to hospital transfer, but by then, the opportunity for timely intervention had passed. Interviews with facility staff revealed a lack of appropriate response to the resident's condition. The Director of Nursing acknowledged that a comprehensive assessment should have been conducted, particularly after the second bout of diarrhea. The resident's physician was informed of the low blood pressure but was not updated with further assessments or changes in the resident's condition. The resident was eventually transferred to the hospital, where he expired the following day due to neutropenic sepsis, secondary to chemotherapy and esophageal cancer.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Florence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Freeman Nursing & Rehabilitation Community | 11.3 mi | ★★★★★ | 5 | 0 |
| Optalis Health And Rehabilitation Of Kingsford | 11.5 mi | ★★★★★ | 4 | 0 |
| Iron County Medical Care Facility | 12.9 mi | ★★★★★ | 0 | 0 |
| Maryhill Manor | 15.5 mi | ★★★★★ | 7 | 0 |
| Iron River Care Center | 21.2 mi | ★★★★★ | 42 | 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 July 2026) and official state health department websites.