Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Four Winds Manor during CMS and state inspections, most recent first.
Two CNAs observed a large bruise on a resident's left upper arm but did not report it as required by facility policy. The injury, later identified as a non-displaced left humerus fracture, was only reported by another CNA on the following shift to an LPN, who then followed protocol. This delay resulted in the incident not being immediately reported to supervisory staff or authorities.
A resident with Parkinson's disease, identified as a fall risk, experienced a fall resulting in a bloody nose when required fall prevention interventions—such as a floor mat and accessible call light—were not in place as specified in the care plan. Staff interviews confirmed that these interventions were expected but not implemented at the time of the incident.
Failure to Assess and Notify Provider for Change in Condition: A resident with HTN, prior cerebral infarction, and encephalopathy developed a severe headache with elevated BP, followed by lethargy, poor intake, and behavior changes. Staff gave Tylenol and recorded vitals, but did not complete a thorough RN assessment or timely MD/NP notification; a voicemail was left instead of direct provider contact. The resident was later sent to the ER and diagnosed with a left occipital lobe subacute infarct.
Food Served at Improper Temperatures: A test tray in the dining room showed hot items below the expected temperature and cold items above the expected temperature, and the surveyor found the meal was lukewarm and not palatable. A cognitively intact resident with HTN and HLD also reported that food was sometimes cold, while the DM, NHA, ANHA, and DON stated food should be served at appropriate temperatures.
Failure to Preserve Resident Dignity During Toileting: A cognitively intact resident with bowel and bladder incontinence reported being made to have bowel movements in bed or in a Depends instead of being assisted to the toilet, despite stating they know when they need to defecate and would prefer toilet use. CNAs confirmed the resident was not transferred to the toilet after becoming a Hoyer transfer, and the DON stated residents should not be expected to defecate in their Depends.
The facility did not ensure that all staff had background checks completed every 4 years as required by its abuse policy. Review of staff records showed that a housekeeper and an LPN were both overdue for required background checks, and the ANHA confirmed that background checks should be completed every 4 years and that both staff members should have been current.
Inaccurate MDS bowel status assessment: A resident with diabetes, HTN, and bipolar disorder had MDS entries that changed from occasional to frequent to always bowel incontinence while also being on a toileting program. The resident told the surveyor she had full bowel control and knew when she needed to have a BM, but also said staff could not transfer her to the toilet with the Hoyer. The MDS nurse said she relied on documentation, did not speak with the resident about bowel continence, was unsure whether CNAs were offering the bedpan, and no toileting program documentation was provided.
A significant med error occurred when an MT crushed and administered a resident’s metoprolol succinate ER tablet with pudding, despite the medication being ordered as extended release and not to be crushed. The order also required a pulse check before administration, but the resident’s pulse was not assessed. The resident had diagnoses including CVA and HTN, and was cognitively intact.
Antibiotic stewardship was not followed for two residents. One resident was treated for a UTI with ciprofloxacin even though the C&S showed resistance, and the line list had no documented symptoms or criteria. Another resident was treated for cystitis with cefpodoxime, but there was no documentation of symptoms, UA, or C&S, and the IP could not verify McGeers criteria from the record.
The facility failed to document education, consent, declination, or vaccine status for two residents regarding pneumococcal immunizations. Both residents had prior pneumococcal vaccines documented, but the facility did not offer the next PCV dose under current CDC guidance, and the DON stated the facility had been following old CDC guidance instead of current guidance.
A resident with dementia was found with a bed sheet wrapped around her midsection in a wheelchair by a CNA during the night shift, allegedly to prevent falls. Despite being advised by an RN that this could be considered a restraint, the CNA proceeded, believing it was necessary for safety. The facility's investigation confirmed the use of the bed sheet as a restraint, which was not in line with the resident's care plan or physician orders.
A facility failed to document a baseline care plan within 48 hours for a resident admitted with orthostatic hypotension, atrial fibrillation, and hypertension. Instead, a care card for CNAs was used, which was not the mandated plan to be shared with the resident or their representative. The Administrator and DON could not locate the baseline care plan, leaving initial care expectations unaddressed.
A CNA failed to follow proper hand hygiene protocols during the care of a resident with an indwelling urinary catheter. Despite multiple glove changes due to the presence of fecal matter, the CNA did not perform hand hygiene between glove changes, even after touching various surfaces. The Director of Nursing confirmed that the expectation was for staff to perform hand hygiene before and after each glove change.
The facility failed to provide residents with food and drink at safe and appetizing temperatures, affecting all 33 residents. Residents from all hallways reported receiving cold meals, and test trays confirmed that food temperatures did not meet policy standards. The Dietary Manager acknowledged challenges in maintaining food temperatures during delivery, leading to lukewarm meals that sometimes required reheating.
The facility did not ensure snacks were offered at bedtime when there was more than a 14-hour gap between supper and breakfast, affecting all residents. Staff indicated snacks were available but not routinely offered unless requested. The Nursing Home Administrator and DON acknowledged the need to offer snacks under these circumstances.
Surveyors found deficiencies in food storage and labeling practices at a facility, with multiple instances of food being improperly labeled and expired items in circulation. Staff interviews revealed unclear responsibilities for monitoring and discarding expired food, affecting the safety and quality of food for all 33 residents.
The facility failed to conduct and document routine diabetic foot checks for residents with diabetes, as required by professional standards. Interviews with nursing staff revealed confusion and inconsistency in performing and documenting these checks, with some staff unaware of the need to use a filament for sensation testing. The Director of Nursing believed checks were being completed daily, but there was no documentation to support this.
The facility's infection prevention and control program was found deficient due to missing lab reports and culture and sensitivity results for residents on antibiotics for UTIs. The Director of Nursing relied on doctors' prescriptions without verifying lab results, and the Wound Nurse did not obtain lab results if they were not included in hospital paperwork. This led to uncertainty about whether residents were on the correct antibiotics.
A resident reported an allegation of abuse to her daughter, who informed the facility. Despite conducting a full investigation and suspending the suspected staff member, the facility failed to report the allegation to the State Agency as required by policy. The resident, who is cognitively intact, alleged that a caregiver pushed her onto the bed and twisted her arm, causing injury.
A resident with pressure injuries did not receive timely wound care upon re-admission to the facility. The facility failed to assess the resident's wounds for six days and missed 13 dressing changes over two months. The resident reported difficulties in receiving wound care, and staff interviews confirmed a lack of adherence to wound care orders and communication between shifts.
Two residents experienced significant weight loss due to the facility's failure to maintain nutritional status and notify the physician. One resident, with conditions including cerebral infarction and dysphasia, lost over 5% of body weight in 30 days without timely physician notification or adequate dietary adjustments. Another resident lost 7.97% of body weight in 30 days, with no physician consultation documented. The facility did not follow its policies on weight monitoring and physician notification, leading to inadequate communication and documentation of the residents' nutritional needs.
A facility failed to develop a comprehensive care plan and policy for a resident requiring dialysis, lacking specific emergency procedures for hemodialysis access site issues. Staff interviews revealed uncertainty in handling such emergencies, with CNAs unsure of appropriate actions. The RN indicated that pressure should be applied and 911 called, but the care plan and facility policy did not include these interventions. The DON acknowledged these deficiencies, and no emergency instruction sign was found in the resident's room.
The facility did not ensure timely physician visits for two residents, who missed required 30, 60, and 90-day visits after admission. One resident with multiple diagnoses, including atrial fibrillation and diabetes, missed a 60-day visit, while another with cerebral infarction and hypertension missed both 60-day and 90-day visits. The DON was unsure of the visit status and the facility lacked a policy for physician visits.
The facility failed to thoroughly investigate an allegation of neglect reported by a Med Tech, who found residents soaked and unattended. Key statements were not obtained, residents were not interviewed, and comprehensive staff training was not provided, highlighting significant gaps in the facility's response.
Failure to Immediately Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving injuries of unknown source were reported immediately to the administrator and appropriate authorities, as required by facility policy and state law. On 10/27/25, two CNAs observed a large bruise on a resident's left upper arm while providing care after dinner. Despite facility policy mandating immediate reporting of such injuries to the supervisor, both CNAs did not report the bruise. The injury was not brought to the attention of supervisory staff until the following shift, when another CNA observed the bruise and reported it to an LPN, who then followed protocol. Further investigation revealed that the resident had sustained a non-displaced left humerus fracture. The facility's policy, dated 8/25, specifies that all injuries of unknown origin must be reported immediately to the Director of Nursing or Administrator, and that all allegations must be reported to the Department of Quality Assurance within specified timeframes. The Nursing Home Administrator confirmed during interview that the initial CNAs failed to report the injury as required, resulting in a delay in notification and investigation of the incident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease, who was identified as being at risk for falls, did not have required fall prevention interventions in place as outlined in their care plan. The resident's care plan specified that a floor mat should be placed next to the bed and that the call light should be within reach before leaving the room. On the date of the incident, the resident was found lying face down on the floor beside the bed with a bloody nose, and it was documented that neither the floor mat was present nor the call light within reach at the time of the fall. Interviews with facility staff, including CNAs and an RN, confirmed that fall interventions are communicated through care plans and CNA care cards, and that these interventions are expected to be in place for residents at risk of falling. The Nursing Home Administrator also acknowledged that staff are expected to follow the care plan and that the interventions for this resident were not implemented at the time of the incident.
Failure to Assess and Notify Provider for Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for a resident who had a change in condition involving a severe headache and elevated blood pressure. The resident had diagnoses including encephalopathy, cerebral infarction, and essential hypertension, and was cognitively intact with a BIMS score of 15. The care plan directed staff to monitor vital signs and headaches, and the facility policy required timely notification of the attending physician/APP and a thorough assessment, including evaluation of relevant systems and a head-to-toe assessment, when a change in condition occurred. On the evening the resident first complained of a bad headache behind his eyes, staff documented a blood pressure of 146/105 and gave Tylenol. The nurse documented that the resident refused a repeat blood pressure check an hour later after stating the headache was gone. The nurse stated she left a message on the NP call line because the NP was on vacation, but she did not speak with a physician or NP. Survey interviews with the caregiver and staff described the resident as not acting like himself, staying in bed unusually, eating less than usual, repeatedly asking for water, and later repeatedly asking for the nurse and pain medication. The nurse reported that no further assessment beyond the blood pressure was completed at that time. Over the next two days, staff documented additional changes in the resident’s condition, including lethargy, refusal to eat, and behavior that was not baseline. One nurse noted the resident appeared lethargic at dinner, was responsive to stimulation, and had vital signs recorded, but there was no evidence of a thorough RN assessment or provider notification. Another nurse described rubbing the resident’s sternum because he was lethargic but responsive, and stated she did not send him to the ER right away. The resident was later sent to the ER after staff reported he had not been at baseline for the last couple of days and was refusing medications. The hospital diagnosed a left occipital lobe subacute infarct, and the discharge summary noted he had presented from the nursing facility with altered mental status for a few days and had neurologic findings including disorientation and visual field loss.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not ensured to be palatable and at a safe and appetizing temperature for residents eating in the main dining room and for one supplemental resident, R29. During a test tray observation on 9/3/25 at 12:39 PM, the surveyor measured the tray items and found Salisbury steak at 124.2 degrees Fahrenheit, buttered noodles at 121.4 degrees Fahrenheit, vegetable medley at 126.9 degrees Fahrenheit, cheesecake at 64.9 degrees Fahrenheit, and milk at 46.9 degrees Fahrenheit. The surveyor tasted the tray and noted the hot items were lukewarm, the cheesecake tasted room temperature, and the milk was not as cold as it should have been. The tray was described as not palatable and not at a safe and appetizing temperature. R29 was admitted with diagnoses including hypertension and hyperlipidemia, and the MDS dated 8/28/25 indicated a BIMS score of 15 out of 15, showing R29 was cognitively intact. On 9/2/25 at 11:44 AM, R29 told the surveyor that the food received was cold sometimes. The Dietary Manager stated that hot food should be above 135 degrees Fahrenheit and cold food should be below 41 degrees Fahrenheit, and the NHA, ANHA, and DON stated they would expect food to be served at the appropriate temperatures.
Failure to Preserve Resident Dignity During Toileting
Penalty
Summary
The facility did not ensure that a resident was treated with dignity and respect in a manner that recognized the resident’s individuality. R17 was admitted with diagnoses including type 2 diabetes mellitus, hypertension, and bipolar disorder, and the most recent MDS indicated a BIMS score of 15 out of 15, showing the resident was cognitively intact. The resident’s MDS history showed bowel and bladder incontinence and toileting program use, and the care plan stated the resident needed two people to help to the bathroom and was partially incontinent. During interview, R17 stated that staff make them have bowel movements in bed and in a Depends, and that staff had not tried to transfer them to the toilet with a Hoyer lift. R17 stated they have full control of their bowels, know when they need to have a bowel movement, and would prefer to use the toilet, saying it makes them feel "icky" to have to go in bed and in a Depends. CNA H stated R17 knows when they need to have a bowel movement but goes in bed, on a bedpan, or in a Depends, and CNA I stated R17 had not been placed on the toilet since becoming a Hoyer transfer because it was considered physically impossible to get someone on the toilet with a Hoyer lift. The DON stated residents should not be expected to defecate in their Depends and was unaware that R17 was having bowel movements in their Depends and occasionally on a bedpan.
Background Checks Not Completed on Schedule
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited because the facility did not ensure that all staff had background checks completed every 4 years as required by its abuse policy. During review of 8 random staff members, the surveyor found that Housekeeper C’s background check was dated 5/12/21 and was due on or before 5/21/25, and LPN D’s background check was dated 11/25/20 and was due on or before 11/25/24. The facility policy stated that employment background checks are completed on all employees through the county’s health and family services department and the Department of Justice at hire and every 4 years thereafter. During interview, the ANHA confirmed that background checks should be completed every 4 years and agreed that Housekeeper C and LPN D should have had their background checks completed timely.
Inaccurate MDS bowel status assessment
Penalty
Summary
The facility failed to ensure that a resident’s assessment accurately reflected her bowel status. R17 was admitted with diagnoses including type 2 diabetes mellitus, hypertension, and bipolar disorder, and her most recent MDS showed a BIMS score of 15/15, indicating she was cognitively intact. However, her MDS Section H bowel status changed over time from occasionally incontinent of bowel on a toileting program, to frequently incontinent of bowel on a toileting program, and then to always incontinent of bowel on a toileting program. Her care plan stated that she needed 2 people to help her to the bathroom and that she was partially incontinent. During interview, R17 told the surveyor that she had to poop in bed, that staff could not transfer her to the toilet with the Hoyer lift, and that she had full control of her bowels and knew when she had to have a bowel movement. The MDS nurse stated she completed the MDS by reviewing documentation and interviewing residents on admission and quarterly, but she did not speak with R17 about bowel continence. She also stated she was unsure whether CNAs were offering the bedpan and acknowledged that a resident cannot be transferred to the bathroom does not automatically mean the resident is incontinent. The MDS nurse reported the toileting program should include toileting upon rising, after breakfast, before and after lunch and supper, and at bedtime, but no documentation of R17’s toileting program was provided. The DON stated the MDS should be accurate and that a toileting program should be documented.
Crushed ER Metoprolol Given Without Required Pulse Check
Penalty
Summary
A significant medication error occurred for R34 when MT G crushed metoprolol succinate ER 25 mg, an extended-release medication ordered to be given once daily by mouth for hypertension, and administered it to the resident with pudding. The order also required a pulse check prior to administration, but the resident’s pulse was not assessed before the medication was given. The report states that extended-release medications are not to be crushed and that the facility policy prohibited crushing long-acting or timed-release dosage forms. R34 was admitted with diagnoses including cerebrovascular accident, hypertension, and hypothyroidism, and her quarterly MDS indicated a BIMS score of 15 out of 15, showing she was cognitively intact. Surveyor observation documented MT G preparing and crushing four medications, including the metoprolol succinate ER tablet, and then administering the crushed medications mixed with pudding to R34. The nursing notes indicated the pulse was not assessed prior to administration, and the DON confirmed that crushing an extended-release medication would be considered a medication error and that the metoprolol order required a pulse check before administration.
Antibiotic Stewardship and Infection Documentation Failures
Penalty
Summary
The facility did not ensure its antibiotic stewardship program was followed for two residents reviewed for antibiotic use. The facility policy stated that the program includes antibiotic use protocols and a system to monitor antibiotic use, and that laboratory testing should follow current standards of practice and McGeers Criteria should be used to define infections. The infection control surveillance policy also stated that documentation of signs and symptoms, physician orders, laboratory reports, and culture findings are used in surveillance activities. For one resident with diagnoses including spinal stenosis and atherosclerotic heart disease, the infection control line listing showed treatment for a UTI with ciprofloxacin, but the record did not document clinical signs of infection or the culture date. The resident’s C&S later showed Proteus mirabilis and Pseudomonas aeruginosa, with ciprofloxacin listed as resistant. Surveyor interview with the IP and RN confirmed the resident had returned from the hospital on ciprofloxacin for UTI, that the organism was resistant to ciprofloxacin, and that the resident should not have received ciprofloxacin because the C&S showed resistance. The IP also stated the resident’s symptoms were not listed on the line listing and that the facility’s process is to ensure the resident and labs meet criteria to treat infection and that the resident is on the correct antibiotic according to C&S. For another resident with diagnoses including cerebral infarction and COPD, the line listing showed treatment for cystitis with cefpodoxime, but there was no documentation of the infection type, clinical signs of infection, or a UA and C&S. The line listing left the infection type blank and listed no organism sensitivity information. During interview, the IP stated there were no symptoms listed on the line listing, could not determine whether McGeers criteria were met from the line listing alone, and acknowledged that the UA and C&S should be in the resident’s medical record.
Failure to Document and Offer Pneumococcal Immunizations
Penalty
Summary
The facility did not ensure that residents or their representatives received education about the benefits and potential side effects of influenza and pneumococcal immunizations before the vaccines were offered, and the medical record did not consistently document whether the resident received the vaccines or refused them due to medical contraindication or declination. This deficiency affected 2 of 5 residents reviewed for immunizations, identified as R6 and R7, and the facility had no declination, education, or consent documentation for either resident regarding the pneumococcal vaccine. R6 was admitted to the facility on 2/26/2024 and had documentation showing receipt of the 13-valent pneumococcal vaccine on 5/21/2015 and the 23-valent pneumococcal vaccine on 11/13/2017. The facility did not offer R6 the next pneumococcal vaccine recommended under current CDC guidance, and no declination or consent was available. R7 had documentation showing receipt of the 13-valent pneumococcal vaccine on 11/11/2014 and the 23-valent pneumococcal vaccine on 10/31/2018. The facility also did not offer R7 the next pneumococcal vaccine recommended under current CDC guidance, and no declination or consent was available. On 9/4/25, the DON provided an email from the pharmacy regarding CDC guidance and stated the facility had been following old CDC guidance rather than current guidance.
Resident Restrained with Bed Sheet for Convenience
Penalty
Summary
The facility failed to ensure the rights of a resident, identified as R4, to be free from physical restraints imposed for convenience. R4, who had a diagnosis of dementia and severe cognitive impairment, was found with a bed sheet wrapped around her midsection while in her wheelchair. This action was taken by a Certified Nursing Assistant (CNA1) during the night shift, allegedly to prevent R4 from falling out of the wheelchair. The facility's policy clearly states that residents have the right to be free from any physical restraint not required to treat the resident's symptoms, and there was no physician order or care plan indicating the need for such a restraint for R4. The incident was reported to the Director of Nursing (DON) by a night nurse, RN1, who observed CNA1 using the bed sheet as a restraint. Despite being advised by RN1 that this could be considered a restraint, CNA1 proceeded with the action, believing it was necessary for R4's safety. CNA1's actions were witnessed by another CNA, who reported the incident to a supervisor. The facility conducted an investigation, which included interviews with staff members and a review of the incident. CNA1 admitted to using the bed sheet but claimed it was not tied and that R4 was able to move freely. The facility's investigation concluded that the use of the bed sheet constituted a restraint, as confirmed by witness statements and CNA1's own account. The incident was reported to the state survey agency, and the facility's investigation was deemed inconclusive. However, the facility acknowledged that CNA1's actions were inappropriate and not in line with the resident's care plan or physician orders. CNA1 was suspended pending further investigation, and the facility recognized the need for re-education on the use of restraints.
Failure to Document Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to provide documentation of a person-centered baseline care plan within 48 hours of admission for a resident, identified as R8, who was admitted with diagnoses including orthostatic hypotension, atrial fibrillation, and hypertension. The facility's policy required the creation of an Initial Resident Baseline Care Plan upon admission, but this was not documented for R8. Instead, a hand-written care card, intended for use by CNAs, was found in the resident's closet. During interviews, RN2 confirmed that this care card was not the mandated baseline care plan that should be shared with the resident and/or their representative. The Administrator and the DON acknowledged that R8's baseline care plan could not be located, and it was unclear if initial care expectations were addressed and communicated to R8 and their representative.
Infection Control Deficiency in Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during the care of a resident with an indwelling urinary catheter. The Certified Nurse Aide (CNA4) was observed performing peri-care for the resident without following the facility's hand hygiene policy. Although CNA4 initially performed hand hygiene before donning gloves, she did not perform hand hygiene after doffing gloves and before donning new ones during multiple glove changes. This occurred despite the presence of fecal matter, which necessitated several glove changes to ensure the resident was clean. During the care process, CNA4 also touched her pocket, a paper towel, and the door of the resident's room without performing hand hygiene before donning new gloves. This lack of hand hygiene continued throughout the care, including after applying nystatin powder to the resident's peri-area and assisting in moving the resident from the bed to a wheelchair. The CNA confirmed the omission of hand hygiene during an interview, and the Director of Nursing stated that the expectation was for staff to perform hand hygiene before and after each glove change.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure that residents received food and drink at a palatable and safe temperature, affecting the entire census of 33 residents. Observations and interviews revealed that residents from all three hallways expressed concerns about food being served cold. The facility's policy on food temperature was not adhered to, as evidenced by test trays and resident feedback. The Resident Council minutes from May to July 2024 documented repeated complaints about cold food, and residents requested meetings with the Dietary Manager and Nursing Home Administrator to address these issues. Specific examples include residents with varying cognitive statuses reporting that their hot meals were often served cold. Test trays ordered by the surveyor showed that food temperatures did not meet the facility's policy standards, with hot dogs served lukewarm and salads not cold enough. The Dietary Manager acknowledged the ongoing issue with maintaining food temperatures and noted that the timing of meal delivery and the effectiveness of tray covers were problematic. The surveyor's observations confirmed that food temperatures were not maintained during delivery, with fried eggs and bacon served at lukewarm temperatures, necessitating reheating in the microwave.
Failure to Offer Bedtime Snacks
Penalty
Summary
The facility failed to ensure that snacks were offered to residents at bedtime when there was more than a 14-hour gap between the evening meal and breakfast. This deficiency was identified through observations, interviews, and record reviews, affecting all 33 residents across three units. Residents expressed concerns during a Resident Council Task meeting about not being offered snacks at bedtime. The facility's posted meal times indicated a 15.25-hour gap between supper and breakfast, which necessitated the provision of bedtime snacks. Interviews with various staff members, including CNAs, an RN, the Dietary Manager, the Nursing Home Administrator, and the Director of Nursing, revealed that snacks were available but not routinely offered to all residents at bedtime. Staff members consistently indicated that snacks were only provided if residents specifically requested them. The Nursing Home Administrator and the Director of Nursing acknowledged that snacks should be offered to all residents when there is more than a 14-hour interval between meals, but this practice was not being followed.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage, labeling, and monitoring of food items. During an inspection, surveyors observed multiple instances of food being removed from original containers without being labeled with an open date. This included items such as coffee, noodles, and various cereals. Additionally, expired food items were found in circulation within the facility's kitchenette, including coffee, prune juice, thickened tomato juice, and cheerios, all past their expiration dates. Furthermore, 29 yogurts were found in the kitchenette refrigerator with expired dates. Interviews with staff, including the Dietary Manager, a CNA, and an RN, revealed a lack of clarity and enforcement regarding the responsibility for monitoring and discarding expired food items. The Dietary Manager indicated that it was the responsibility of all staff to date and label food in the shared kitchenette and to discard expired items. However, the presence of expired and unlabeled food suggests a failure in implementing these policies effectively, potentially affecting the safety and quality of food provided to all 33 residents in the facility.
Failure to Conduct and Document Diabetic Foot Checks
Penalty
Summary
The facility failed to ensure that residents with diabetes received routine diabetic foot checks in accordance with professional standards of practice. This deficiency was identified for four residents, all diagnosed with type 2 diabetes mellitus, who had no documentation of diabetic foot checks in their medical records. The facility's policy required diabetic foot checks upon admission and quarterly or upon significant change in condition, but there was no evidence that these checks were being performed or documented. Interviews with nursing staff revealed a lack of clarity and consistency regarding the performance and documentation of these checks, with some staff unaware of the requirement to use a filament for sensation testing. The surveyor's interviews with various nursing staff, including RNs, LPNs, and the Wound Nurse, highlighted confusion and inconsistency in the implementation of diabetic foot checks. Some staff believed checks were supposed to be done daily, while others were unsure of the procedure or documentation requirements. The Wound Nurse indicated that CNAs were previously tasked with performing foot checks, although they are not qualified to assess. The Director of Nursing was under the impression that checks were being completed and documented daily, but this was not the case, as confirmed by the lack of documentation in the Treatment Administration Record (TAR).
Inadequate Infection Control Program Due to Missing Lab Reports
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by the lack of proper documentation and follow-up on lab reports and culture and sensitivity (C&S) reports for residents on antibiotics. Specifically, the facility's infection control line lists did not include necessary lab reports for residents diagnosed with urinary tract infections (UTIs), resulting in uncertainty about whether the residents were on the correct antibiotics. This deficiency was observed in one sampled resident and three supplemental residents, who were placed on antibiotics without the facility obtaining their urine culture and sensitivity results to confirm the appropriateness of the prescribed antibiotics. Interviews with the Director of Nursing (DON), who also serves as the Infection Preventionist, and the Wound Nurse (WN), who handles admissions, revealed a lack of a clear process for obtaining lab results when residents are admitted from or return from the hospital. The DON admitted to relying on doctors' prescriptions without verifying lab results, while the WN stated that she only has lab results if they are included in the hospital paperwork and does not reach out to obtain them otherwise. This lack of a systematic approach to ensuring residents are on the correct antibiotics contributed to the deficiency in the facility's infection prevention and control program.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R4, to the State Agency within the required timeframe. R4, who is cognitively intact with a BIMS score of 14 out of 15, reported to her daughter that a caregiver had pushed her onto the bed, causing injury to her hip, and twisted her arm. This incident was reported by R4's daughter to the Director of Nursing (DON B) on July 25, 2024. Despite conducting a full investigation, including staff and resident interviews, and suspending the suspected staff member, the facility did not report the allegation to the State Agency as required by their policy. The facility's policy mandates that all allegations of abuse must be reported to the State Agency immediately or within 24 hours, or within 2 hours if the incident involves serious bodily injury. However, in this case, the DON B acknowledged receiving the report of abuse from R4's daughter but failed to report it to the State Agency. The surveyor's interview with DON B revealed that the DON was unaware of the requirement to report the allegation, despite the facility's policy clearly stating the obligation to do so. This oversight resulted in a deficiency in the facility's compliance with state reporting requirements for abuse allegations.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure injuries, as required by professional standards of practice. Upon re-admission, the resident's wounds were not assessed for six days, contrary to the facility's policy that mandates a wound assessment within 24 hours of admission or re-admission. The resident, who had a deep tissue injury on the right heel and a stage 2 pressure injury on the left heel, reported challenges in receiving wound care, missing at least four dressing changes in a month due to the unavailability of nursing staff. The facility's Medication/Treatment Administration Record indicated that the resident missed 13 dressing changes over a two-month period. Interviews with the LPN and DON revealed that the facility did not adhere to the wound care orders, and there was a lack of communication and follow-through between shifts to ensure the resident's wound care was completed. The DON acknowledged the failure to perform the required wound assessments and treatments, describing the situation as unacceptable.
Failure to Maintain Nutritional Status and Notify Physician
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for two residents, leading to significant weight loss without timely physician notification. Resident R25, admitted with conditions including cerebral infarction and dysphasia, experienced a weight loss of over 5% within 30 days. Despite initial dietary assessments identifying weight loss as a concern, the facility did not provide additional calories or identify R25's food preferences to facilitate better oral intake. The physician was not notified of significant weight changes, and the resident's nutritional supplements were inconsistently managed. Resident R29 also experienced significant weight loss, with a 7.97% decrease in body weight over 30 days. The facility failed to notify the physician of this weight loss, and there was no documentation of physician consultation regarding the weight changes. Despite a care conference, there was no mention of the resident's meals or weights, and the resident was discharged without the necessary weight monitoring instructions being included in the discharge paperwork. The facility's policies on weight monitoring and physician notification were not followed, as evidenced by the lack of timely updates to the physician and the absence of documented consultations. The Registered Dietician and nursing staff did not adequately communicate or document the residents' nutritional needs and preferences, contributing to the residents' continued weight loss and the facility's failure to address these issues effectively.
Deficiency in Dialysis Care Planning and Emergency Procedures
Penalty
Summary
The facility failed to develop a comprehensive care plan and policy and procedures consistent with professional standards of practice for a resident requiring dialysis care. The resident, who receives renal dialysis three times a week, did not have a care plan that included necessary care and treatment approaches for dialysis, particularly in emergency situations related to the hemodialysis access site. The facility's policy on hemodialysis care lacked specific interventions for emergent care, such as applying pressure if the resident was found to be bleeding from the dialysis access site. Interviews with staff revealed a lack of knowledge and preparedness for handling emergencies related to the resident's dialysis access site. Certified Nursing Assistants (CNAs) were unsure of the appropriate actions to take if the resident was found bleeding from the fistula, with one CNA stating she would activate the call light and find a nurse, while another was uncertain but thought she would seek a nurse. A Registered Nurse (RN) indicated that staff should apply pressure and call 911 in such situations, and that any staff member, including CNAs, could and should apply pressure. The Director of Nursing (DON) acknowledged the absence of specific interventions in the care plan and facility policy, and it was noted that there was no sign with emergent instructions in the resident's room, contrary to what the DON believed.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician every 30 days for the first 90 days after admission and every 60 days thereafter, as required. This deficiency was identified for two residents, R14 and R25, out of a sample of 16. R14, who was admitted with diagnoses including atrial fibrillation, type 2 diabetes, major depressive disorder, osteomyelitis, and heart failure, was not seen by a physician in July, missing a 60-day visit after admission. Similarly, R25, admitted with diagnoses of cerebral infarction, hypertension, and dysphasia, was not seen by a physician in June or July, missing both 60-day and 90-day visits after admission. During an interview on August 6, 2024, the Director of Nursing (DON B) was unable to confirm whether R14 and R25 were current with their required physician visits. Although DON B acknowledged the expectation for physician visits at designated intervals, the facility was unable to provide a policy for physician visits when requested by the surveyor.
Failure to Investigate Allegations of Neglect
Penalty
Summary
The facility did not ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that steps were taken to prevent further potential abuse. Med Tech D reported an allegation of neglect, stating that CNA C did not toilet or change residents during her shift, resulting in residents on the D-Wing being soaked. The facility failed to obtain statements from both Med Tech D and CNA C, did not interview any residents, and did not provide training to all staff to ensure this does not occur again. This lack of thorough investigation and follow-up is a clear deficiency in the facility's response to the allegation of neglect. The facility's self-report indicates that CNA C worked her normal shift and was assigned to B-Wing, while CNA E was assigned to A-Wing and could not assist with D-Wing due to quarantine precautions. Med Tech D arrived at 2:00 AM and found residents on D-Wing soaked, indicating that they had not been changed for an extended period. Despite this, the facility did not document any negative effects reported by the residents and concluded that CNA C did not intentionally neglect her duties. However, the facility's investigation was incomplete as it did not include statements from key individuals or interviews with the affected residents. R4, a resident with a BIMS score of 15 indicating cognitive intactness, reported being left wet for extended periods on multiple occasions, including the incident in question. Despite this, the facility did not include R4's account in their self-report. The facility's failure to obtain necessary statements, interview residents, and provide comprehensive staff training highlights significant gaps in their investigation process and response to allegations of neglect.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 341 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Verona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Badger Prairie Hcc | 0.5 mi | ★★★★★ | 9 | 0 |
| Complete Care At Maple Grove Llc | 2.3 mi | ★★★★★ | 0 | 0 |
| Hebron Oaks | 3.5 mi | ★★★★★ | 3 | 0 |
| Oak Park Place Of Nakoma | 5.5 mi | ★★★★★ | 19 | 0 |
| Middleton Village Nursing And Rehab | 7.3 mi | ★★★★★ | 21 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.