Below average — CMS composite of the measures below.
The next survey window likely opens 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 Greendale Park Nursing And Rehab during CMS and state inspections, most recent first.
Pressure injury care and prevention were not consistently implemented for multiple residents. A resident with extensive neurologic disease, diabetes, malnutrition, and prior wounds was observed without heel offloading at times and had a necrotic left heel area with no current assessment, measurements, or treatment documented. Two other residents at risk for skin breakdown were repeatedly found in bed without heel boots despite care plans and physician orders, and another resident’s heel injury was not comprehensively assessed until it was later documented as unstageable.
PBJ Staffing Data Not Accurately Submitted: The facility did not ensure PBJ staffing information was accurately submitted to CMS based on payroll and other verifiable data. Survey review found the 4th quarter PBJ report triggered for excessively low weekend staffing, even though the weekend staffing schedules and facility assessment showed staffing levels that were intended to meet resident needs. BOM-L stated corporate HR payroll staff normally entered the PBJ data, but the facility had not had corporate HR staff since 8/1/25. He later found that extra salaried RN hours for two RNs did not pull through into the payroll data, contributing to the inaccurate PBJ submission.
Infection control deficiencies were identified when the facility failed to maintain a complete water management plan and did not consistently use TBP, EBP, hand hygiene, PPE, or equipment disinfection. A resident with loose stools and a C-diff order was not placed on contact precautions, and another resident returned on antibiotics for pneumonia without droplet precautions. Staff were also observed sorting soiled laundry without proper PPE, failing to perform hand hygiene during med pass and resident care, and not sanitizing a glucometer after use.
Failure to Offer and Document COVID-19 Vaccination: The facility did not ensure eligible residents were offered the COVID-19 vaccine or that vaccination status was properly documented. Record review showed signed consents for several residents with diagnoses including COPD, MS, malnutrition, immunodeficiency, CHF, asthma, and chronic respiratory failure, but no evidence the vaccine was offered or administered. The IP/ADON stated immunization information is collected on admission and an order is obtained if the resident consents, but the records reviewed did not show follow-through for these residents.
A resident with MS, COPD, insomnia, and other chronic conditions had Melatonin 5 mg gummies kept at the bedside and reported taking 2 gummies nightly, but there was no physician order for the Melatonin or for self-administration. Although the care plan and a self-administration assessment indicated the resident could self-administer and keep meds at bedside, the DON confirmed the required orders were missing, and the EMR did not document physician follow-up about the bedside Melatonin.
A resident’s wheelchair was repeatedly observed with food particles and other debris alongside and under the cushion. Surveyors saw a large accumulation of debris on the wheelchair over multiple observations, including scrambled eggs and dirt covering the seat area under the cushion. Staff stated wheelchairs were supposed to be cleaned on third shift, and an LPN acknowledged the wheelchair was dirty.
A resident with dementia, anxiety, depression, CKD, DM, and hospice services was started on Seroquel for agitation and yelling out after family concerns, but the record did not show documented nonpharmacological interventions or assessment/rule-out of underlying medical conditions before the antipsychotic was ordered. Staff interviews described redirection and hand-holding, while the MAR behavior monitoring was incomplete and the NP noted no pain documentation.
Failure to Provide Written Transfer/Discharge and Bed Hold Notices: Three residents were transferred to the hospital without documented written notice of the reason for transfer/discharge in a language they or their representatives could understand. The facility also used bed hold forms that lacked required appeal-rights details, and staff described a process that relied on verbal notification or signatures when available rather than documented written notice.
A resident with MS, spastic hemiplegia, and ROM impairment was ordered to wear a right-hand resting splint at night as tolerated, and OT notes showed the splint had been provided and tolerated with good skin integrity. Surveyors repeatedly observed the splint left on the bedside table while the resident slept without it on, and the record did not document consistent refusal. The resident said staff had not been helping put the splint on, OT said staff should assist with donning and doffing, and CNAs reported they were unaware of the splint order.
Failure to Maintain Fall-Prevention Interventions and Investigate Repeated Falls: A resident with dementia and severe cognitive impairment was repeatedly observed without ordered fall-prevention items in place, including a body pillow, floor mat, and accessible call light, despite care plan interventions. Another resident with multiple medical conditions and severe cognitive impairment had repeated falls related to toileting and bathroom attempts, but the facility’s fall investigations were incomplete and did not consistently identify root cause, last observation, last toileting time, or whether prior interventions were in place.
A facility failed to consistently complete pre- and post-dialysis assessments and maintain communication with the dialysis center for two residents receiving hemodialysis. One resident had severe cognitive impairment and multiple chronic conditions, while the other was cognitively intact and reported the facility did not manage the dialysis access site. Record review showed multiple missed or incomplete dialysis communication forms and missing assessment documentation, and staff interviews confirmed the gaps in the process.
A resident with a long history of suicidal ideation and diagnoses including bipolar disorder and major depression voiced suicidal thoughts in the dining room on two occasions. Staff documented the statements, but the record did not show the resident was placed on the ordered 1:1 observation, and the physician, psych services, and social services were not promptly notified. Surveyors also found no documentation of the required checks after the first event, despite the care plan and suicide prevention policy directing immediate reporting and continuous supervision.
Failure to Ensure Flu and Pneumococcal Vaccinations Were Offered and Documented: The facility did not ensure that residents were offered annual influenza immunization and pneumococcal immunization as required. Two residents had signed flu vaccine consents in their records, but surveyors could not find evidence that the flu vaccine was offered or administered; one resident also had pneumonia vaccine documentation completed, while the other resident's flu vaccine had not been given until after surveyor inquiry.
An incident of physical abuse between two residents was not reported to the state survey agency within the required two-hour timeframe. An LPN witnessed the altercation and notified the DON, who then contacted the ADM. Due to misunderstanding of the reporting policy, the ADM submitted the report the next day instead of immediately as required.
The facility did not complete a thorough investigation into an incident of resident-to-resident abuse, failing to interview or document statements from witnesses, including two residents and staff who observed the event. Despite policy requirements to interview all involved and maintain complete records, key witness accounts were missing from the investigation documentation.
A required discharge MDS assessment was not completed or transmitted for a resident who was transferred to the hospital and did not return. Review of the electronic health record and staff interviews confirmed the omission, with the MDS coordinator unable to provide a reason for the oversight. Both the DON and NHA were notified of the missing assessment.
A resident with a G-tube did not receive enteral feeding according to physician orders, as the feeding continued during scheduled off times and staff were unclear about the feeding schedule. Additionally, there were no documented interventions or orders for monitoring or caring for the G-tube site, despite facility policy requiring such care. The resident, who was nonverbal and dependent on staff, was observed with leaking tube feeding and lacked appropriate site monitoring and documentation.
A resident was transferred or discharged without adequate preparation to ensure their needs and preferences were met, resulting in a failure to provide a safe and individualized transition.
Two residents were transferred to the hospital on multiple occasions without receiving the required written transfer and bed-hold notices, which should have included details such as the reason for transfer, bed-hold duration, appeal rights, and ombudsman contact information. Review of records and staff interviews revealed that the facility did not consistently provide or document these notices, and staff were unclear about who was responsible for this process.
Two residents with significant cognitive and physical impairments did not have comprehensive, person-centered care plans addressing urinary incontinence, including measurable objectives and timeframes. Although staff reported providing incontinence care every two hours or as needed, this frequency was not documented in the care plans or CNA Kardex, and documentation of care provided was inconsistent. Nursing staff and management acknowledged that care plans lacked specific instructions, resulting in a deficiency in meeting regulatory and facility policy requirements.
A medication error rate above 5% was identified when an LPN failed to prime both Humalog and Glargine insulin pens before administration and did not date the Glargine pen upon opening, as observed during a medication pass for a resident. Interviews confirmed that facility policy requires priming and dating of insulin pens, but the LPN was unaware of the correct procedure.
A resident was not protected from a significant medication error, as required, due to a failure in medication administration or management.
A resident with multiple comorbidities and incontinence was admitted with several stage 2 pressure injuries and MASD. The facility failed to conduct timely skin assessments and did not implement appropriate wound treatments upon admission and readmission. No treatment was provided for several days, resulting in the development and worsening of a stage 3 pressure injury that required surgical debridement. An incontinence care plan was not implemented, and appropriate wound care was delayed until the resident was seen by a wound physician.
A resident with a history of diverticulosis and constipation did not receive appropriate bowel monitoring or interventions upon admission, despite being at risk due to medical history and opioid use. Documentation of bowel elimination was inconsistent, and staff failed to assess or address the resident's complaints of nausea and diarrhea. After a hospital visit revealed significant stool burden, recommended medication changes were not implemented, and a care plan for constipation risk was not initiated. Staff interviews revealed gaps in communication and documentation, and the facility could not provide a bowel monitoring policy when requested.
A resident with severe cognitive impairment, total incontinence, and existing pressure injuries did not have an individualized incontinence care plan implemented, despite facility policy and clinical indications. The care plan and Kardex lacked specific interventions such as a check and change schedule, and staff interviews confirmed the absence of documented incontinence management, contributing to ongoing skin complications.
A resident at high risk for pressure injuries did not receive adequate care upon admission, leading to a facility-acquired pressure injury. The facility failed to conduct a comprehensive skin assessment and delayed implementing treatment orders. Inaccurate wound assessments and missed treatments further compromised the resident's care, despite interventions like heel boots and an air mattress.
A resident with multiple health issues experienced a fall from bed, found with an arm stuck in a bed rail, due to inadequate supervision and lack of a prior bed rail assessment. The facility failed to conduct a thorough investigation or reassess the appropriateness of the bed rails, leading to discrepancies in staff accounts and insufficient updates to the resident's care plan.
A resident with mobility impairments and cognitive intactness was found with bed rails installed without a prior risk assessment, contrary to facility policy. The resident's arm became entrapped in the bed rail, requiring emergency services. Staff interviews revealed that therapy assessments were not completed before bed rail installation, and the facility administration acknowledged the oversight without providing further information.
The facility's assessment was found lacking essential details on water management, infection prevention, and infectious disease management, potentially affecting all 76 residents. The DON acknowledged the omission during a surveyor's review and provided an updated assessment after being informed of the necessary components.
The facility failed to ensure RN coverage for at least eight consecutive hours daily on 17 days and did not designate a charge nurse for each shift. Staffing schedules lacked clarity on RN and agency staff roles, and the omission of charge nurse assignments was acknowledged as an error. Despite efforts to hire RNs and use agency staff, the facility struggled to maintain required coverage.
The facility failed to maintain an effective infection prevention and control program, with an outdated Water Management Plan lacking current standards and testing for Legionella. A resident's medication was handled barehanded by a nurse, breaching infection control practices. The facility's infection surveillance was inaccurate, missing a COVID-19 case, and the facility assessment lacked infection prevention information. Staff interviews revealed a lack of awareness and proper implementation of infection control measures.
The facility did not ensure that five CNAs completed the required annual 12 hours of educational training. CNA-C completed only 8 hours, and CNA-D completed only 7 hours in the last 12 months. This deficiency was identified through a record review and staff interview, with no explanation provided for the incomplete training.
A resident's medical record lacked a signed advance directive form for CPR, despite facility policy requiring this upon admission. The resident, with multiple health issues, had no care plan for advance directives, and the form was only completed after a surveyor's request. Interviews revealed the guardian had not signed the form, and there was no documentation of discussions about advance directives.
A facility failed to provide appropriate dialysis care for a resident, lacking physician orders, assessments, and a care plan for dialysis. The resident, with complex medical needs, did not have coordinated care with the dialysis center, and the facility's DON was initially unable to provide necessary information. The care plan was only updated after surveyor inquiry, indicating a deficiency in managing the resident's dialysis needs.
The facility failed to properly assess and obtain informed consent for bed rail use for two residents, with assessments not updated and consent not documented. Additionally, there was no routine maintenance schedule for bed rails, contrary to facility policy. These deficiencies were noted during surveyor interviews and observations.
The governing body of a facility failed to implement effective financial management policies, resulting in significant arrears with multiple vendors. This included essential services like pharmacy, food distribution, and medical equipment, threatening service disruptions. Interviews revealed a lack of awareness among staff about the financial issues, with responsibilities deferred to external consultants. The facility's financial instability could impact the care and safety of all residents.
A facility failed to prevent abuse by not implementing proper screening procedures for a CNA, who was later involved in an allegation of sexual assault against a resident. The CNA inaccurately completed a BID form, and the facility did not verify the DOJ background check or obtain references. This allowed the CNA to care for a resident who alleged sexual abuse, creating immediate jeopardy.
A resident did not receive a CBC and BMP as ordered due to a break in lab service from unpaid bills, which was not documented. The resident experienced multiple episodes of diarrhea, but the facility failed to assess the condition or obtain a stool sample to rule out infection. The resident was later diagnosed with dehydration, C-Diff, and a UTI at the hospital. The facility did not follow its incontinence policy, leading to a deficiency in care.
The facility failed to provide adequate pressure ulcer care and prevention for two residents at high risk for pressure injuries. One resident developed a stage 3 pressure injury and a DTI, while another developed a DTI, with care plans not revised to include necessary interventions. Initial assessments and treatments were delayed, and documentation was lacking, leading to deficiencies identified by surveyors.
The facility failed to provide required annual QAPI training to 4 out of 5 CNAs, as per their policy. The DON acknowledged a change in training software, which led to the inability to verify training completion. Only one CNA had completed the QAPI training, while the facility could not provide documentation for the others, potentially affecting all 69 residents.
A resident self-administered Entresto for heart failure without a proper assessment, physician's order, or care plan in place. The facility's policy requires an interdisciplinary team assessment and documentation for self-administration, which was not completed. The issue was identified, and the facility began administering the medication to the resident.
A resident's right to privacy was breached when their package was opened by an LPN without permission. The LPN was instructed by a receptionist to open the package, suspecting it contained knives, but it was actually medication. The facility's policy states that residents' mail should not be opened by staff, yet this incident occurred, leading to the resident's upset.
The facility failed to promptly investigate and resolve grievances for three residents during a survey. Despite having a grievance policy, the facility did not document or investigate grievances until prompted by the surveyor. Concerns about staff behavior and call light responses were not addressed, and documentation was incomplete, resulting in unresolved grievances.
The facility failed to report two incidents of alleged abuse involving residents to the State survey agency within the required timeframe. An allegation of sexual assault was not reported immediately, and a physical abuse allegation was reported two days late. The facility's policy requires timely reporting, but these incidents were not reported as mandated.
The facility failed to thoroughly investigate allegations of abuse, misappropriation, and neglect involving three residents. A resident with cognitive impairment reported a sexual assault, but not all staff on duty were interviewed. Another resident reported missing money and inappropriate behavior by a CNA, but the investigation lacked interviews with all relevant staff. A third resident alleged neglect, but staff were not questioned about their knowledge of the incident.
A resident did not receive documented showers over a month-long period, despite requiring substantial assistance for bathing. The facility's new system for tracking showers failed to ensure the resident's hygiene needs were met, as confirmed by staff interviews and lack of documentation.
A resident with hemiplegia and bilateral above-knee amputation did not receive adequate supervision and fall prevention interventions as outlined in their care plan. Despite the plan's directives, observations revealed the absence of a body pillow on the bed's right side and the call light not consistently within reach. The LPN confirmed these measures should have been in place, but no explanation was provided for the oversight.
A resident with Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Sleep Apnea did not receive appropriate respiratory care as the facility failed to document MD orders for CPAP settings and cleaning, and did not include CPAP use in the care plan. The LPN Unit Manager confirmed the need for such documentation, which was missing, and the issue was noted during a surveyor's investigation.
Two residents in the facility experienced significant medication errors due to unavailable medications. One resident, with a kidney transplant, missed six doses of Tacrolimus, while another, with heart failure, missed nine doses of Ivabradine. The facility's process for handling unavailable medications was inadequate, lacking clear policies on notifying providers and missing necessary medications in the contingency supply.
A resident with diabetes and bilateral above-knee amputations had inaccurate medical records indicating daily diabetic foot checks were performed, despite the absence of feet. The facility's MAR inaccurately documented these checks as completed, which was confirmed through a surveyor's review and staff interviews.
Pressure Injury Care and Offloading Not Consistently Implemented
Penalty
Summary
The facility did not ensure appropriate pressure ulcer care and prevention for multiple residents with pressure injuries or who were at risk for developing them. The report states that 4 of 6 residents reviewed for pressure injuries were affected: R41, R2, R60, and R10. The facility policy required individualized interventions, implementation of physician orders, documentation in the care plan, and documentation of compliance with interventions in the medical record. R41 had multiple diagnoses including cerebral infarction, hemiplegia, multiple sclerosis, diabetes, malnutrition, paraplegia, and a history of pressure ulcers. Survey observations showed R41 was sometimes lying on his back with feet resting directly on the mattress and at other times was not wearing heel boots, despite care plan interventions to encourage heel boots at all times and repositioning side to side. The surveyor observed a darkened brown necrotic area on the left heel, but there was no current assessment, measurement, or treatment documented for that heel area. The wound physician and DON stated there was no documentation of the left heel wound in the physician notes, and the facility could not determine when the pressure injury developed. R2 and R60 were both documented as at risk for pressure injuries and had care plans and Kardex instructions for heel boots while in bed. Survey observations repeatedly found R2 in bed with no heel boots on and both heels directly on the mattress, and R2 stated the boot had not been put on for about a month and that he had not refused it. R60 was also repeatedly observed in bed without heel boots, with heels directly on the mattress, despite physician orders and care plan interventions for bilateral heel boots while in bed. The record also showed no documented monitoring of R60’s refusals, and the resident stated staff frequently did not put the boots on and that his heels were sore. R10 was admitted with a right heel injury, but the comprehensive assessment was not completed until the wound was later documented as unstageable. The admission note described a 1 cm hematoma to the right heel, yet there was no further documentation of assessment until the wound physician note on 8/6/25, which documented an unstageable pressure injury and ordered treatment. The report also states there was no documented evidence that R10’s heels were offloaded prior to that assessment. Overall, the facility did not consistently implement, document, or monitor pressure-relieving interventions and did not maintain adequate assessment and treatment documentation for residents with pressure injuries.
PBJ Staffing Data Not Accurately Submitted
Penalty
Summary
The facility did not ensure its PBJ staffing information was accurately submitted to CMS based on payroll and other verifiable and auditable data. Survey review found the facility’s 4th quarter 2025 PBJ data triggered for excessively low weekend staffing. The surveyor reviewed weekend staffing schedules and the facility assessment, and the staffing levels shown on the schedules coincided with the staffing needs documented in the assessment. During interviews, the Scheduler-AA stated the weekend staffing schedule showed sufficient staff to meet residents’ needs. BOM-L stated he was responsible for collecting payroll data and entering it into the facility payroll system, while corporate HR payroll staff were responsible for entering data into the PBJ system; he also stated the facility had not had corporate HR staff since 8/1/25. When asked about the low weekend staffing trigger, BOM-L identified the facility’s cut point as 2.9 and the facility’s level as 2.7. He later reviewed payroll in more depth and found salaried RN-J worked extra hours on 8/10/25 and salaried RN-BB worked extra hours on 7/10/25, but those hours did not pull through into the payroll data.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as evidenced by multiple observations and record reviews showing that transmission-based precautions, enhanced barrier precautions, hand hygiene, PPE use, and equipment disinfection were not consistently implemented. The report also identified that the facility did not have a current comprehensive water management plan with facility-specific flow charts or documentation available for review. Surveyor interviews with maintenance and nursing leadership confirmed that the water management binder could not be located and that staff were unsure of the current status of the plan or its mapping documentation. For one resident, the record showed loose stools and a physician order to send stool for C-diff, but transmission-based precautions were not in place. The resident also returned from the emergency room after coughing up bloody sputum and was placed on Augmentin for pneumonia, yet droplet precautions were not implemented. Facility staff later acknowledged that contact precautions should have been used for loose stools or C-diff testing and that droplet precautions should have been used when the resident returned on antibiotics for pneumonia. The report also noted that no TBP signage or PPE cart was posted outside the resident’s room during survey observations. Additional observations showed infection control lapses during resident care and routine tasks. A laundry aide sorted dirty laundry without appropriate PPE and did not perform hand hygiene after removing gloves. During medication administration for one resident, an LPN did not perform hand hygiene after removing gloves and before putting on new gloves. For another resident receiving blood sugar testing, the glucometer was not sanitized after use. Staff caring for residents on EBP, including residents with indwelling catheters, were observed entering rooms without hand hygiene, not donning gowns when required, not changing gloves appropriately, and not performing hand hygiene after care. The report also documented that EBP signage and PPE supplies were missing or not in place for at least one resident who had an indwelling catheter.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility did not develop and implement policies and procedures to ensure that when the COVID-19 vaccine was available, each resident was offered the vaccine unless it was medically contraindicated or the resident had already been immunized. The facility policy stated that residents and staff were to be educated and offered the COVID-19 vaccine, and that documentation of education, consent, and vaccination status would be maintained. The Infection Preventionist/Assistant Director of Nursing stated that upon admission nurses complete a document asking about immunizations and, if the resident wants the vaccine or consents, an order is obtained. Review of the records for four residents showed signed COVID-19 vaccine consents but no evidence that the vaccine was offered or administered. R2 had diagnoses including MS, COPD, and protein-calorie malnutrition; a signed consent was uploaded to the EHR, but no evidence of offer or administration was found. R9 had diagnoses including muscle wasting and atrophy, protein-calorie malnutrition, immunodeficiency, COPD, malignant neoplasm of the sigmoid colon, and chronic CHF; a signed consent was present, but no evidence the vaccine was offered or given was located. R35 had diagnoses including COPD, asthma, and chronic respiratory failure with hypoxia; a signed consent was present, but no evidence the vaccine was offered or given was located. R54 had diagnoses including malignant neoplasm of colon, severe protein-calorie malnutrition, immunodeficiency, chronic CHF, and adult failure to thrive; no evidence the vaccine was offered or given was located.
Missing physician order for self-administered bedside Melatonin
Penalty
Summary
The facility failed to ensure that a resident who was keeping Melatonin 5 mg at the bedside had a physician order for the medication and a physician order to self-administer medications. The facility’s policy required an interdisciplinary assessment and a prescriber’s order before a resident could self-administer medications, and it also required documentation of the determination in the medical record and care plan. In this case, the resident’s care plan documented that the resident was able to safely administer medications, and a self-administration assessment completed on 10/27/25 approved the resident to self-administer and keep medications at bedside, but the resident’s physician orders did not include an order to self-administer and the surveyor could not locate an order for Melatonin. The resident was admitted with multiple diagnoses including Multiple Sclerosis, Spastic Hemiplegia affecting the right dominant side, Neuromuscular Dysfunction of Bladder, Irritable Bowel Syndrome with Diarrhea, Type 2 Diabetes Mellitus, COPD, Insomnia, and Major Depressive Disorder. The Quarterly MDS documented a BIMS score of 15, indicating the resident was cognitively intact for daily decision making. The MDS also documented significant physical assistance needs, including wheelchair use, range of motion impairment, substantial or maximum assistance with showers, upper dressing, and mobility, dependence for lower dressing and transfers, and an indwelling catheter. Survey observations showed a bottle of Melatonin 5 mg gummies on the resident’s overbed table on multiple occasions, and the resident stated taking 2 gummies every night. The resident also stated not keeping track of taking the Melatonin on a nightly basis. The DON confirmed the resident should have a physician order for the Melatonin and for self-administration, but later stated the resident would not give up the Melatonin and the physician would not give the order due to conflicts. The surveyor noted there was no documentation in the EMR that the physician had been contacted about the Melatonin at bedside, and the Melatonin remained at the resident’s bedside throughout the observations.
Dirty wheelchair cushion and debris accumulation
Penalty
Summary
The facility did not ensure a clean environment for 1 resident, identified as R67. Surveyors observed food particles and other debris alongside and under the resident’s wheelchair cushion on multiple occasions. On 1/20/26, R67 was observed sitting in the wheelchair in his room, and the right side of the wheelchair, between the cushion and the side, had a large accumulation of food particles and other debris. On 1/21/26, the same area of the wheelchair again contained a large accumulation of food particles, including scrambled eggs, and other debris. On 1/22/26, surveyors observed CNA-Q, CNA-O, and LPN/WN-T in R67’s room during care. When the resident was lifted from the wheelchair and the cushion was raised, surveyors observed under the cushion covering the entire seat portion of the wheelchair a large accumulation of food, dirt, and other debris. CNA-Q stated wheelchairs were supposed to be cleaned on third shift, and LPN/WN-T said she did not know there was debris under the cushion. LPN-H also stated third shift was supposed to clean wheelchairs and acknowledged the wheelchair was dirty with food particles and debris under the cushion.
Unnecessary psychotropic medication used without documented nonpharmacological interventions
Penalty
Summary
The facility did not ensure a resident was free from unnecessary psychotropic medication use when Seroquel 25 mg twice daily was started for agitation and yelling out without documented nonpharmacological interventions being attempted and without documentation that underlying medical conditions were ruled out. The resident had diagnoses including chronic kidney disease, diabetes mellitus, anxiety disorder, depression, and dementia, and received hospice services with an activated healthcare POA. The resident’s care plan included interventions for anxiety and agitation such as redirection, reassurance, soothing activities, and offering food, fluids, toileting, massage, and a quiet environment. The resident’s records showed behavior monitoring on the MAR, but the documentation consisted of shift checks without the numbered behavior categories being recorded. A social service note documented a behavior/GDR meeting and stated the resident was stable, with psych following and no changes recommended. Shortly afterward, nursing notes documented the daughter’s report of new agitation and yelling out, hospice contact, and then a nurse practitioner assessment that led to the new order for quetiapine for dementia with agitation. The first dose was given the same day, and subsequent notes described continued monitoring of the new medication and intermittent yelling out that was often redirected. During surveyor interviews, facility staff gave differing explanations about why the medication was started and what was done before it was ordered. An LPN stated the resident’s daughters were concerned and wanted something to calm her down, and that the resident was already on Buspar and did not want lorazepam. An LPN/unit manager stated only redirection, talking, and hand-holding were used, and was not sure whether pain or other underlying conditions had been assessed. The hospice RN stated the medication was started because of increased agitation, yelling, and resistance to care. The NP stated the behaviors were verbal and that she did not have documentation of pain assessment, and she relied on discussion with hospice to select the medication. The social service director later stated that nonpharmacological interventions, further medication discussion, and psych involvement should have occurred before prescribing the antipsychotic.
Failure to Provide Written Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility did not ensure that residents and/or their representatives were notified in writing of the reason for transfer or discharge, and the bed hold notice used by the facility did not contain all required appeal-rights information. The report identified three residents, R2, R35, and R34, whose transfer/discharge notices were not provided in writing in a language understood by the resident and/or representative. The facility also could not provide a bed hold and transfer notice policy and procedure when requested. R2, who was cognitively intact with a BIMS score of 15 and had diagnoses including multiple sclerosis, spastic hemiplegia, neuromuscular bladder dysfunction, IBS with diarrhea, type 2 diabetes, COPD, insomnia, and major depressive disorder, was sent to the hospital multiple times. For the 8/6/25 transfer, the record showed the resident requested hospital transfer and an ambulance was called, but there was no documentation that a bed hold and transfer notice was provided. For the 10/21/25 and 12/7/25 transfers, the forms indicated the resident was verbally informed, but the forms were not acknowledged by a facility representative as having been provided in writing in a language the resident could understand. The resident later told the surveyor that he had been out to the hospital several times but never signed acknowledgment of the bed hold and notice of transfer in writing. R35, who was cognitively intact with a BIMS score of 14, was also transferred to the hospital more than once. The record showed hospital transfers on 8/19/25 and 12/2/25, but the facility could not provide documentation that a bed hold and transfer notice was provided in writing to R35 and/or the representative. R34, who had diagnoses including traumatic brain injury, encephalopathy, conversion disorder, and seizures and had an activated POA, was transferred to the hospital on multiple occasions. For several transfers, the chart showed only verbal notification to the POA, and the surveyor could not locate written bed hold and notice of transfer forms for some transfers. For other transfers, the forms present in the record did not include required appeal-rights information, including email addresses for all listed agencies and an address for the ombudsman, and the forms did not show evidence that they were provided in writing.
Failure to Apply Ordered Right-Hand Splint
Penalty
Summary
The facility did not ensure a resident with limited ROM received appropriate treatment and services to maintain or improve mobility and prevent further decrease in ROM. The resident had diagnoses including Multiple Sclerosis, spastic hemiplegia affecting the right dominant side, and ROM impairment on one side of both upper and lower extremities. The resident’s MDS documented wheelchair use, substantial to maximum assistance needs for mobility and self-care, and the care area assessment identified ROM impairment with a goal to minimize risks and demonstrate improvement. The resident had a physician order for a right-hand resting splint to be worn at night as tolerated, and OT notes documented that the resident was provided the splint, tolerated it with good skin integrity, and staff were able to assist with donning and doffing. The resident’s Kardex also directed that the right resting hand splint be worn at night as tolerated, and the comprehensive care plan included the splint intervention. However, the January 2026 MAR/TAR did not show the splint being monitored for placement every evening, and the record did not document that the resident consistently refused the splint. Survey observations showed the splint repeatedly left on the bedside table while the resident slept without it on the right hand. The resident stated the splint was not placed on the hand the prior night and said the resident would wear it every night if staff helped put it on. OT confirmed the resident should be wearing the splint at night and had never been told the resident refused it or found it painful. CNA interviews showed staff were unaware the resident had a right-hand splint or did not know the resident was supposed to wear one, and the facility provided no additional information explaining why the resident was not wearing the splint as ordered.
Failure to Maintain Fall-Prevention Interventions and Thoroughly Investigate Repeated Falls
Penalty
Summary
The facility did not ensure adequate supervision and assistance devices were in place to prevent accidents for a resident with chronic kidney disease, diabetes mellitus, anxiety, depression, and dementia. The resident’s care plan included interventions such as a body pillow to be applied to the door side of the bed and a floor mat on the door side of the bed. The resident’s quarterly MDS showed short- and long-term memory problems, severe impairment in cognitive skills for daily decision making, dependence for toilet use and transfers, and total incontinence of bowel and bladder. During multiple survey observations, the resident was found in bed without the body pillow and without the floor mat that were listed in the care plan and Kardex, and the call light was observed under the pillow and not within reach. Survey observations on multiple occasions showed the resident in bed without the ordered body pillow or floor mat, including while sleeping and during morning care. A CNA provided care and transferred the resident to a chair, but before leaving the room did not place the body pillow or floor mat. Another CNA later entered the room and again did not place the body pillow or floor mat. When asked, a CNA acknowledged that the floor mat was not present and identified rolled items in the room as the items that had been on the bed. An LPN stated that CNAs should follow the resident’s plan of care and that staff are informed of extensive interventions through the Kardex, but the resident’s ordered fall-prevention items were not consistently in place during the observations. The facility also did not thoroughly investigate repeated falls for another resident with a history of traumatic brain injury, hypertension, end stage renal disease, diabetes mellitus, encephalopathy, conversion disorder, and seizures. The resident had multiple falls associated with trying to get to the bathroom, needing a bowel movement, or being found in the bathroom or on the floor. The facility’s investigations for several falls consisted of incident reports, neuro checks, and limited staff statements, but did not consistently identify the root cause or include key details such as when the resident was last observed, when the resident was last toileted, what the resident was doing before the fall, or whether prior interventions were in place. In some investigations, staff statements did not witness the fall or provide care, and the facility did not consistently determine the cause of the repeated falls.
Failure to Maintain Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care and services for two residents who required hemodialysis. The facility’s own policy stated that residents receiving hemodialysis were to have ongoing assessment before and after dialysis, monitoring for complications, and ongoing communication and collaboration with the dialysis facility. In the records reviewed, the facility did not consistently complete pre-dialysis or post-dialysis assessments and did not consistently document communication from the dialysis center for either resident. One resident had diagnoses including traumatic brain injury, hypertension, end stage renal disease, diabetes mellitus, encephalopathy, and conversion disorder with seizures or convulsions. The resident’s care plan included monitoring for edema, daily thrill and bruit checks, and observation for bleeding. The resident also had severe cognitive impairment with a BIMS score of 6. Survey review of the dialysis binder and medical record showed multiple dialysis dates where the facility did not complete the pre-dialysis assessment, did not complete the post-dialysis assessment, and/or had no communication from the dialysis center. On several dates, the bottom portion of the dialysis communication form was not completed by the dialysis center, and on other dates there was no pre- or post-dialysis assessment documented at all. A second resident had diagnoses including a non-displaced condyle fracture of the lower end of the right femur, Type 1 diabetes mellitus, and end stage renal disease requiring dialysis. The resident was cognitively intact with a BIMS score of 15. The care plan included written communication between the dialysis provider and the facility regarding weights and changes in condition. During interview, the resident stated the facility did not do anything with the access site and that the dressing was changed at dialysis. The resident also reported that paperwork had only been sent to dialysis twice. Surveyor review and staff interviews confirmed that the facility was not consistently completing pre- and post-dialysis assessments and that communication with the dialysis center was not consistently occurring.
Failure to Follow Suicide Precautions and Notify Behavioral Health Providers
Penalty
Summary
The facility did not ensure a resident with a long history of suicidal ideations received the behavioral health care and services identified in the plan of care after he voiced suicidal thoughts in the dining room on two occasions. The resident had diagnoses including bipolar disorder, major depressive disorder, generalized anxiety disorder, hypertension, diabetes mellitus, and obsessive-compulsive personality disorder, and his care plan directed staff not to leave him alone if he expressed suicidal ideation and to initiate 1:1 observation, inform nursing, and call 911. The facility’s suicide prevention policy also required immediate reporting of suicidal ideation to the charge nurse and social worker, immediate physician notification, and provision of 1:1 care until emergency psychiatric care could be arranged or the physician determined the risk was no longer present. After the first suicidal statement, a late entry note documented that the resident told staff he wanted to slit his wrist and said he had done that in the past, but he was feeling depressed and needed to talk it out. The record did not show that he was placed on 1:1 observation as directed by the care plan, and surveyors did not find evidence that the physician or psychological services were notified at that time. Social service staff were unaware of the suicidal ideation when interviewed, and the facility could not provide documentation of the interventions that were implemented after the event. After the second suicidal statement, the resident told a CNA in the dining room that he was having suicidal thoughts but would not harm himself and did not want to go to the hospital. Nursing documented that the on-call nurse assessed for a plan and found none, and the resident was reassured and remained in the facility. Surveyors later found that social services and the DON were not aware of the suicidal ideation until days later, and the facility could not show that psychiatric services were notified at the time. When questioned, the LPN/UM who wrote the earlier note stated the resident was placed on the 24-hour board and thought he may have been on 15-minute checks, but she did not provide documentation of those checks, and the resident’s care plan still called for 1:1 observation.
Failure to Ensure Influenza and Pneumococcal Immunizations Were Offered and Documented
Penalty
Summary
The facility did not ensure that residents were offered influenza immunization between October 1 and March 31 annually and did not ensure that residents were offered pneumococcal immunization unless medically contraindicated or already immunized. The facility policy titled Influenza Vaccination stated that annual influenza immunization would be offered from October 1 through March 31 unless contraindicated, already received during that time period, or refused, and that consent and documentation of education and immunization status would be maintained in the medical record. During interview, the IP/ADON stated that upon admission nurses complete an immunization document and, if the resident wants the vaccine and consents, an order is obtained. Review of records for two residents showed missing follow-through on the immunization process. One resident had diagnoses including muscle wasting and atrophy, protein-calorie malnutrition, immunodeficiency, COPD, malignant neoplasm of the sigmoid colon, and chronic CHF; the record showed a signed consent for influenza and pneumonia vaccine, and WIR showed the pneumonia vaccine was completed, but surveyors could not locate evidence that the influenza vaccine was offered or given. Another resident with diagnoses including COPD, asthma, and chronic respiratory failure with hypoxia had a signed influenza vaccine consent in the record, but surveyors could not locate evidence that the influenza vaccine was offered or given. When questioned, the IP/ADON reported that one resident refused the flu vaccine only after surveyor inquiry and that the other resident's flu vaccine had not been given and would be given that day.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident physical abuse to the state survey agency within the required two-hour timeframe. According to facility policy, all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made. In this case, an altercation occurred in which one resident hit another on the shoulder after being run into by a power wheelchair. The incident was witnessed by an LPN, who notified the Director of Nursing (DON) shortly after the event. The DON then contacted the Administrator (ADM), who was responsible for reporting abuse allegations to the state survey agency. Despite the policy requirements, the ADM submitted the abuse report to the state survey agency the following day, well beyond the two-hour window. Interviews revealed that both the DON and ADM were unclear about the correct reporting timeframe, with the DON believing the report was due within 24 hours and the ADM unaware that all abuse allegations required reporting within two hours, regardless of injury severity. Both residents involved had intact cognition and no behavioral symptoms documented during recent assessments.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of resident-to-resident abuse involving two residents. According to facility policy, all involved persons, including witnesses, should be identified and interviewed, and complete documentation of the investigation should be maintained. However, the investigation did not include interviews or documentation from key witnesses who were present during the incident, such as two other residents and staff members who observed the altercation. The incident in question involved one resident hitting another on the shoulder, followed by a physical response. Both residents involved had intact cognition as indicated by their BIMS scores, and neither exhibited behavioral symptoms during their respective assessment periods. The event was reported promptly to the state survey agency, and staff separated the residents at the time of the incident. Despite this, the facility's investigative documents lacked statements or interviews from the witnesses who were present, including two residents with intact cognition and staff who directly observed the event. Interviews with facility staff revealed that the social services director and the director of nursing were unaware that other residents had witnessed the incident, and there was no documentation of interviews with the staff members who responded to the event. The administrator confirmed that all present during the incident should have been interviewed, but the investigation records did not reflect this. As a result, the facility did not meet its own policy requirements for a complete and thorough investigation of the abuse allegation.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a required discharge Minimum Data Set (MDS) assessment for one of two residents reviewed for MDS assessments and transmission. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) Manual, all Medicare and/or Medicaid-certified nursing homes must transmit required MDS data records, including discharge assessments, to the Centers for Medicare and Medicaid Services' (CMS) Internet Quality Improvement Evaluation System (iQIES). The discharge assessment is to be completed no later than 14 calendar days after the discharge date. In this case, a resident was admitted to the facility and later transferred to the hospital, not returning to the facility. Upon review of the electronic health record, it was found that no discharge MDS assessment was completed or transmitted after the resident's discharge. During interviews, the MDS coordinator confirmed that a discharge MDS assessment is typically completed within seven days of a resident's discharge, but acknowledged that no such assessment was completed for this resident and was unsure why it was missed. The deficiency was confirmed through record review and staff interviews, with both the Director of Nursing and the Nursing Home Administrator being informed of the missing discharge MDS assessment. No additional information or explanation for the omission was provided by facility staff.
Failure to Follow G-Tube Feeding Orders and Provide Site Care
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube (G-tube) did not receive care and services in accordance with physician orders and facility policy. The resident had an order for enteral feeding with Jevity 1.5 at 65 mL/hour for 20 hours, to be stopped at 10:00 AM and restarted at 2:00 PM. However, multiple observations by the surveyor showed that the tube feeding continued to run during the period it was supposed to be off. Staff members, including CNAs and an LPN, were unclear about the feeding schedule, with some believing the feeding was continuous. The feeding was also observed to be leaking, resulting in formula on the resident's bed sheet. Further review revealed that there were no physician orders or documented interventions for monitoring, treatment, or care of the resident's G-tube site. The facility's policy required daily assessment and care of the G-tube site, including cleaning, monitoring for infection, and documentation of care provided. Interviews with staff, including the LPN, unit manager, and DON, confirmed that there were no orders or documentation for G-tube site monitoring or care on the resident's MAR/TAR or care plan. Staff were unsure about the expectations for G-tube care and could not locate relevant information in the resident's records. The resident in question had significant medical needs, including anoxic brain damage, chronic respiratory failure, protein-calorie malnutrition, and was dependent on staff for all activities of daily living. The resident was nonverbal, unable to follow commands, and at high risk for malnutrition. Despite these vulnerabilities, the facility failed to ensure that the resident's G-tube feeding was administered as ordered and that appropriate monitoring and care of the G-tube site were provided and documented.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. This deficiency was identified based on observations and documentation that indicated the resident's individual requirements and choices were not fully considered or addressed during the transfer/discharge planning process. As a result, the resident was not properly prepared for a safe transition, and the necessary steps to ensure their needs and preferences were met were not completed.
Failure to Provide Required Transfer and Bed-Hold Notices During Hospitalizations
Penalty
Summary
The facility failed to provide required written transfer and bed-hold notices to two out of three residents reviewed who were hospitalized. Specifically, the facility did not issue documentation to the residents or their representatives that included the date and reason for transfer, location of transfer, duration of bed-hold, appeal rights, and contact information for the State Long-Term Care Ombudsman. This omission was identified through interviews and record reviews, which revealed that no such notices were found in the electronic health records (EHR) for the residents in question. One resident with diagnoses including muscle wasting, acute and chronic respiratory failure, and a tracheostomy was transferred to the hospital on three separate occasions. Progress notes documented the clinical events leading to each transfer, such as labored breathing, trach removal, and sepsis, but there was no evidence that the required transfer and bed-hold notices were provided or documented in the EHR. Another resident with multiple chronic conditions and an activated healthcare power of attorney was also transferred to the hospital, and again, no written notice was found in the EHR for this event. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for issuing transfer and bed-hold notices. The Nursing Home Administrator, Social Services Director, Admissions Director, RN Unit Manager, and Health Unit Coordinator each gave differing accounts of who was responsible for providing and documenting these notices. Some staff believed the notice was only required at admission or monthly, rather than at each transfer, and others were unaware of the requirement altogether. This lack of consistent process and documentation led to the deficiency.
Failure to Develop Comprehensive Incontinence Care Plans with Measurable Objectives
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes to address the urinary incontinence needs of two residents. For one resident with severe cognitive impairment, multiple comorbidities, and total dependence for activities of daily living, the care plan lacked specific instructions regarding the frequency of incontinence care. Although staff interviews indicated that incontinence care was generally provided every two hours or as needed, this frequency was not documented in the resident's care plan or on the CNA Kardex. Additionally, documentation of incontinence care provided was inconsistent, with significant gaps in the electronic health record regarding the number and timing of urinations. For another resident with a history of stroke, diabetes, chronic respiratory failure, and moderate cognitive impairment, the care plan also failed to include a person-centered approach to incontinence care. The resident was assessed as always incontinent of urine and bowel and dependent on staff for all care. While the CNA Kardex and staff interviews indicated that incontinence care was provided every two hours or as needed, there was no specific care plan developed to address the resident's incontinence needs, nor was the frequency of care documented in the care plan or Kardex. Interviews with nursing staff and management confirmed that the facility's practice was to provide frequent check and change for incontinent residents, but this was not consistently reflected in the care plans. The lack of measurable objectives and timeframes in the care plans for both residents did not meet the facility's own policy requirements or regulatory expectations for comprehensive, person-centered care planning.
Medication Error Rate Exceeds 5% Due to Insulin Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required, with a calculated error rate of 5.88% based on 2 errors in 34 observed opportunities. During medication administration, a Licensed Practical Nurse (LPN) did not prime a resident's Humalog insulin pen prior to dialing the prescribed dose, contrary to facility policy and procedure. The same LPN also failed to prime the resident's Glargine insulin pen before administration and did not ensure the insulin pen was dated when opened, as required for tracking expiration. These actions were directly observed by the surveyor during the medication pass. Interviews with the LPN and the Unit Manager confirmed that insulin pens should be primed with 2 units before each use and dated upon opening, with the Unit Manager stating that insulin expires 28 days after being opened. The LPN demonstrated a lack of knowledge regarding the priming procedure, stating incorrectly that priming was not necessary. The surveyor verified these deficiencies through direct observation, interviews, and review of facility policy, resulting in the identification of two medication errors for the resident.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the administration or management of medications as required by regulations. No further details about the specific actions, inactions, or the condition of the resident(s) at the time of the deficiency are provided in the report.
Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
A deficiency occurred when a resident with multiple pressure injuries did not receive timely and appropriate assessment and treatment upon admission and readmission. The facility's own policies required a comprehensive skin assessment by a licensed or registered nurse upon admission and weekly thereafter, as well as prompt implementation of evidence-based wound treatments in accordance with physician orders. However, after the resident was admitted with several stage 2 pressure injuries and moisture-associated skin damage (MASD), no treatment was implemented for five days until the wound physician evaluated the resident. During this period, the resident developed a stage 3 pressure injury on the coccyx, which required surgical debridement. Upon the resident's readmission following hospitalization, the facility again failed to conduct a comprehensive assessment and did not implement appropriate treatments for the existing pressure injuries. The clinical admission note indicated that skin issues had not been evaluated, and the documentation and measurements were unchanged from the previous admission, despite the presence of a stage 3 pressure injury. Only a barrier cream was applied two days after readmission, which was not an appropriate treatment for a stage 3 pressure injury. It was not until five days after readmission, when the wound physician evaluated the resident, that the stage 3 pressure injury was found to have worsened and required further debridement. Throughout this period, the resident, who had significant medical comorbidities including severe hypoxic ischemic encephalopathy, chronic respiratory failure, and incontinence, did not have an incontinence care plan implemented. The lack of timely assessment, failure to initiate appropriate wound care, and absence of an incontinence care plan contributed to the progression and exacerbation of the resident's pressure injuries, as documented by both facility records and wound care specialists.
Failure to Provide Bowel Monitoring and Timely Interventions for Resident at Risk of Constipation
Penalty
Summary
A resident with a history of diverticulosis, constipation, and other significant medical conditions was admitted to the facility and did not have a care plan initiated for bowel monitoring or interventions, despite being at risk due to their medical history and opioid use. There was no documentation of bowel elimination until several days after admission, and the first recorded bowel movement was diarrhea, accompanied by complaints of nausea. The resident was not assessed or monitored for these symptoms, and there was no documentation regarding the nausea and diarrhea. Additionally, bowel elimination was not consistently documented every shift, and staff interviews revealed inconsistent practices and lack of communication regarding the resident's symptoms. The resident was later transferred to the hospital for evaluation of nausea and abdominal cramping, where a CT scan revealed moderate colonic stool burden and a mildly distended rectal vault, correlating with constipation. Upon readmission to the facility, hospital recommendations to increase laxative use and add MiraLAX were not implemented, and a care plan for constipation risk and bowel monitoring was still not initiated. Physician orders from the hospital were not promptly addressed, and staff interviews indicated a lack of awareness and follow-through regarding the resident's bowel status and related symptoms. Throughout the resident's stay, there was a lack of comprehensive assessment and documentation when the resident experienced gastrointestinal symptoms, such as nausea and diarrhea. Staff failed to consistently monitor, document, and communicate the resident's bowel status and related complaints, and did not implement or update care plans or interventions as required by professional standards of practice and the resident's needs. The facility also could not provide a bowel monitoring policy when requested by the surveyor.
Failure to Implement Incontinence Care Plan for Resident with Pressure Injuries
Penalty
Summary
A deficiency was identified when a resident who was always incontinent of bowel and bladder, and admitted with pressure injuries and Moisture Associated Skin Damage (MASD), did not have an individualized care plan implemented to manage incontinence. The facility's own policy required staff to assess, document, and manage incontinence, including the use of a check and change strategy to protect skin integrity, but this was not reflected in the resident's care plan or Kardex. The resident's records indicated total dependence for toileting hygiene and bed mobility, and the presence of a stage 3 pressure injury and MASD, yet there was no documentation specifying the frequency of incontinence checks or changes. Surveyor interviews with facility staff, including the Nurse Practitioner and the Acting Director of Nursing, confirmed that while the need for moisture management and skin care was communicated, there was no evidence of a specific incontinence care plan or schedule being implemented. The Nurse Practitioner noted that the MASD was likely due to a combination of incontinence-related wetness and shearing, and emphasized the importance of routine checking and changing. However, neither the care plan nor the Kardex included these interventions, and staff were unable to provide additional documentation or clarification during the survey. The lack of a personalized incontinence management plan for the resident, who was at high risk for skin breakdown and had existing pressure injuries, was directly observed and confirmed through record review and staff interviews. This omission was cited as a failure to provide appropriate treatment and services to prevent further skin-related complications, as required by facility policy and regulatory standards.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and treatment to prevent and heal pressure injuries for a resident, identified as R8, who was at risk for developing such injuries. Upon admission, R8's skin was not assessed, and an individualized care plan was not developed based on R8's risks and care needs. The facility also delayed implementing treatment orders for R8's pressure injuries, which were documented in the hospital discharge paperwork. The contracted wound care provider's assessments incorrectly identified the location of the wounds, and the facility's wound assessments were not comprehensive. R8 was admitted with diagnoses including muscle wasting, epilepsy, dysphagia, dementia, and peripheral vascular disease. The hospital discharge paperwork noted unstageable pressure injuries on R8's left great toe and right heel, but the facility did not place treatment orders until several days after admission. The facility's care plan for R8 included interventions for altered skin integrity and pressure injury prevention, but these were not effectively implemented. R8's Braden Scale assessments indicated a high risk for developing pressure injuries, yet the facility's assessments were inconsistent and did not accurately reflect R8's condition. The facility's failure to conduct a comprehensive skin assessment upon admission and the delay in implementing treatment orders contributed to the development of a new facility-acquired pressure injury on R8's right great toe. Additionally, the facility's skin assessments were not completed according to current standards of practice, lacking detailed characteristics and measurements of the wounds. The facility also missed wound care treatments on specific dates, further compromising R8's care. Despite the presence of heel boots and an air mattress, R8 was observed with heels resting directly on the bed, indicating inadequate pressure relief measures.
Inadequate Supervision and Bed Rail Assessment Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent falls for a resident, identified as R8, who was found on the floor with his left arm stuck in a bed rail. The incident occurred without a prior bed rail assessment, which is a necessary step before applying bed rails to a resident's bed. The facility did not conduct a thorough investigation to determine the root cause of the fall, nor did they reassess the appropriateness of the bed rails for R8. Additionally, the care plan was not updated in a timely manner to include interventions that could prevent future falls. R8, a resident with multiple diagnoses including muscle wasting, epilepsy, and dementia, was admitted to the facility and assessed as dependent on staff for mobility and transfers. Despite being cognitively intact, R8 experienced a fall from bed, which was not witnessed by staff. The facility's fall investigation revealed discrepancies in the documentation of the incident, such as the position in which R8 was found and the fact that his arm was stuck in the bed rail, which was not initially mentioned in the investigation report. Interviews with staff, including the Director of Therapy and a Licensed Practical Nurse, highlighted a lack of communication and awareness regarding the incident. The Director of Therapy was unaware of the incident involving the bed rail, and the LPN provided conflicting accounts of the event. The facility's failure to conduct a comprehensive investigation and reassessment of the bed rail use, along with the discrepancies in staff statements, contributed to the deficiency in providing a safe environment for R8.
Failure to Assess Bed Rail Risks Leads to Resident Entrapment
Penalty
Summary
The facility failed to assess the risk of entrapment and review the risks and benefits of bed rail use for a resident, leading to a deficiency. The resident, who is dependent on staff for mobility and has a history of muscle wasting, epilepsy, and dementia, was observed with bed rails on both sides of the bed without a completed side rail risk assessment. The facility's policy requires a person-centered approach and a comprehensive assessment before bed rails are used, including evaluating alternatives and obtaining informed consent, which was not followed in this case. The resident's medical record indicated that on a specific date, the resident's left arm became stuck in the bed rail, necessitating emergency medical services. Despite this incident, a bedrail/mattress safety assessment was only completed the following day, determining the resident was safe to have assist bed rails. Observations by the surveyor on subsequent days found the resident unattended with bed rails still in place, and the resident confirmed the recent incident of entrapment. Interviews with facility staff revealed that therapy is responsible for assessing bed rail needs, but the assessment was not completed before the bed rails were applied. The Director of Therapy confirmed that an assessment should be completed prior to bed rail installation. The surveyor notified the facility's administration of the concerns regarding the lack of assessment before the bed rails were used, but no additional information was provided by the facility leadership.
Facility Assessment Lacks Critical Information
Penalty
Summary
The facility failed to ensure that the Facility Assessment was updated to include critical information regarding the water management committee, the infection preventionist, and infectious disease management. This oversight has the potential to affect all 76 residents residing in the facility. On October 3, 2024, a surveyor reviewed the Facility Assessment and found that it lacked details on water management, the infection preventionist, and infectious disease management. During an interview on October 7, 2024, the Director of Nursing (DON) acknowledged that the recent update to the Facility Assessment accidentally omitted this information. The surveyor informed the DON of the necessary components that should be included in the Facility Assessment. Later that day, the DON provided an updated copy of the Facility Assessment after the surveyor requested the missing information. The surveyor also communicated these concerns to the Assistant Director of Nursing and the Assistant Nursing Home Administrator.
Deficiency in RN Coverage and Charge Nurse Designation
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, on 17 out of 152 days reviewed. This deficiency was identified through a review of the Payroll Based Journal (PBJ) report and staffing schedules, which showed that the facility did not meet the required RN coverage on specific dates. The Scheduler acknowledged the issue, citing challenges such as staff call-ins and difficulties in hiring RNs, despite attempts to fill gaps with agency staff. The Director of Nursing (DON) and Administrator were aware of the low RN hours and were actively trying to hire additional RNs, but the facility still lacked adequate RN coverage on the noted days. Additionally, the facility did not designate a charge nurse for each shift, as the staffing schedules did not indicate which nurse was assigned this role. The Scheduler admitted that the schedules should reflect the RN and agency staff, and that the omission of charge nurse assignments was an error. The DON stated that staff typically knew who was in charge, as they carried a phone to signify their role, but no additional information was provided to explain why the charge nurse was not identified on the schedule.
Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which has the potential to affect all 76 residents. The Water Management Plan (WMP) was outdated and did not reflect current standards of practice. It lacked the inclusion of the Infection Preventionist (IP) and did not have current water testing for Legionella, with the last test conducted in June 2023. The facility's surveillance of the infection control program was also inaccurate, as it failed to include a resident who tested positive for COVID-19 in September. During the survey, it was observed that a nurse handled a resident's medication with bare hands during preparation, which is a breach of infection control practices. The facility's policy on infection prevention and control, implemented in October 2022, was not adhered to, as evidenced by the lack of proper documentation and communication regarding the water management program and infection surveillance activities. The facility's assessment also lacked information on infection prevention and water management, which was acknowledged by the Director of Nursing as an accidental omission. Interviews with facility staff revealed a lack of awareness and proper implementation of the water management program. The Director of Maintenance admitted to not conducting necessary water testing for Legionella or other pathogens, and the Regional Director was unaware of the current water testing procedures. The Assistant Director of Nursing acknowledged the failure to accurately track and document COVID-19 cases, attributing it to a lack of communication and oversight. These deficiencies highlight significant gaps in the facility's infection prevention and control measures, posing a risk to resident safety.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that five Certified Nursing Assistants (CNAs) completed the required annual 12 hours of educational training. Specifically, CNA-C and CNA-D did not meet the training requirements, with CNA-C completing only 8 hours and CNA-D completing only 7 hours of training in the last 12 months. This deficiency was identified through a record review and staff interview conducted by the surveyor. The Nursing Home Administrator and Director of Nursing were informed of these findings, but no additional information was provided to explain why the facility did not ensure the completion of the required training hours.
Failure to Complete Advance Directive Forms for Resident
Penalty
Summary
The facility failed to ensure that a resident's medical record contained signed advance directive election forms, specifically regarding Cardiopulmonary Resuscitation (CPR). The resident, who had multiple diagnoses including muscle wasting, atrial fibrillation, and dementia, was admitted without a completed advance directive form. The facility's policy requires that upon admission, the facility should determine if a resident has an advance directive and provide information about the right to refuse treatment. However, the resident's CPR consent form was not completed until the surveyor requested it, and there was no care plan for advance directives initiated. Interviews with facility staff revealed that the resident's guardian had not signed the form, and there was no documentation of discussions with the resident or guardian regarding advance directives. The Director of Nursing acknowledged that the code status should be included in the care plan, but it was not. The surveyor noted that the form was only completed after the issue was brought to the facility's attention, and there was still no physician order or care plan for the resident's advance directive in the electronic medical record.
Deficiency in Dialysis Care Coordination
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident, identified as R426, who required such services. Upon admission, R426 did not have physician orders for hemodialysis or the frequency of dialysis sessions. Additionally, there were no assessments completed before or after dialysis sessions, and no care plan was in place to monitor and care for R426 in relation to dialysis and potential complications. The facility also lacked communication with the dialysis center for each visit, which is a critical component of coordinated care. R426 was admitted with multiple diagnoses, including sepsis, acute pyelonephritis, legionnaires' disease, dependence on renal dialysis, rhabdomyolysis, end-stage renal disease, and type 2 diabetes mellitus. Despite these complex medical needs, the facility's records did not reflect any physician orders or assessments related to dialysis sessions. The care plan for R426 was only updated after the surveyor's inquiry, indicating a lack of proactive management of the resident's dialysis needs. The Director of Nursing (DON) was unable to provide information regarding the resident's dialysis care when initially asked by the surveyor. It was later revealed that there was no communication between the facility and the dialysis center regarding R426's condition and treatment. The facility's policy required comprehensive care plans and coordination with the dialysis provider, which were not adhered to in this case. The lack of documentation and communication highlights a significant deficiency in the facility's management of dialysis care for R426.
Deficiencies in Bed Rail Assessment and Maintenance
Penalty
Summary
The facility failed to ensure proper assessment and informed consent for the use of bed rails for two residents, R7 and R66. R7's Bed Rail Assessment and Informed Consent for Use were not updated since early 2024, despite the presence of grab bars on both sides of the bed. The facility's policy requires these assessments to be reviewed quarterly, but this was not adhered to, as confirmed by the Director of Nursing (DON). R66 had a right grab bar attached to the bed frame, but there was no evidence that risks were explained or informed consent was obtained. The Bed Rail Assessment form for R66 was unsigned, and no informed consent was documented. Additionally, the facility did not enforce a routine maintenance and inspection schedule for bed rails. The Director of Maintenance confirmed that checks on bed canes were only performed when they were removed and reinstalled, with no scheduled inspections when the canes remained on the bed. This lack of regular maintenance and inspection was highlighted during the surveyor's interviews with facility staff. The facility's policy on the proper use of bed rails emphasizes a person-centered approach, requiring comprehensive assessments and informed consent before installation. However, the facility failed to comply with these guidelines, as evidenced by the lack of updated assessments and informed consent for R7 and R66, and the absence of a regular maintenance program for bed rails. These deficiencies were communicated to the facility's leadership during the surveyor's end-of-day meetings.
Governing Body's Financial Mismanagement Leads to Vendor Payment Delays
Penalty
Summary
The facility's governing body failed to establish and implement effective policies and procedures for managing and operating the facility, leading to significant financial mismanagement. This deficiency was identified during a survey where it was found that the facility's fiscal accounts were in arrears, affecting the payment to multiple vendors. The governing body did not ensure that contracted vendors were reimbursed and paid according to established contracts or invoiced amounts, which could potentially impact the care and treatment of all 75 residents in the facility. The survey revealed that the facility owed substantial amounts to various vendors, including those providing essential services such as waste management, pharmacy services, human resources consulting, electronic medical records, food distribution, and medical equipment. For instance, the facility owed over $1.2 million to AlixaRx for pharmacy services, with invoices outstanding for more than 151 days. Additionally, the facility had significant outstanding balances with Sysco Baraboo, a food distributor, and Point Click Care Technologies, which provides electronic medical records, both of which threatened service disruptions due to non-payment. Interviews with facility staff, including the Business Office Manager and the Nursing Home Administrator, indicated a lack of awareness or involvement in the financial issues, with responsibilities for payment and vendor management being deferred to external entities or consultants. The facility's financial instability was further highlighted by the outstanding balances owed to the Wisconsin Department of Health Services for bed tax fees and civil money penalties issued by CMS. The governing body's failure to ensure fiscal stability and oversight has the potential to affect the safety and care of all residents in the facility.
Failure to Prevent Abuse Due to Inadequate Screening
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, specifically in the case of a CNA who was involved in an allegation of sexual assault against a resident. The CNA inaccurately completed a Background Information Disclosure (BID) form by answering 'no' to a question about past criminal convictions, despite having a conviction for fourth-degree sexual assault. The facility did not verify the positive results of the Department of Justice (DOJ) background check against the BID form, nor did it obtain references for the CNA as part of the hiring process. This lack of thorough screening allowed the CNA to care for a resident who later alleged sexual assault. The resident involved in the allegation had a history of right and left above-knee amputation, hemiplegia and hemiparesis following cerebral infarction, anxiety disorder, and depression. The resident was assessed as cognitively intact in April but showed a decline to moderate cognitive impairment by June. The resident alleged that the CNA entered her room, touched her inappropriately, and forced her to touch him. Despite calling for help, no staff responded at the time of the incident. The resident reported the incident to a social worker the following morning, who then notified the Director of Nursing, the police, and the resident's Power of Attorney. The facility's failure to ensure the accuracy of the CNA's BID form and to conduct thorough background and reference checks allowed the CNA to provide care to a vulnerable resident, resulting in the resident alleging sexual abuse. This deficiency created a finding of immediate jeopardy, indicating a reasonable likelihood for serious harm. The facility's inaction in verifying the CNA's background and responding to the resident's calls for help contributed to the severity of the situation.
Failure to Provide Adequate Care and Monitoring for Resident with Diarrhea
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The resident, identified as R6, did not receive a complete blood count (CBC) and basic metabolic panel (BMP) during the specified week as ordered by the physician. This lapse in care was attributed to a break in service from the lab due to unpaid bills by the facility, which was not documented or communicated effectively. Additionally, there was no documentation of the resident refusing the lab work, as claimed by the LPN/UM. R6 experienced multiple episodes of loose, watery diarrhea, which were documented by CNAs but not adequately assessed by the facility. Despite the documentation of 14 episodes of diarrhea, the facility did not obtain a stool sample to rule out an infectious process. The resident was eventually discharged to a family member and subsequently diagnosed with dehydration, C-Diff, and a urinary tract infection at the hospital. The delay in ordering Metamucil and the lack of a comprehensive assessment of the resident's bowel condition contributed to the deficiency. The facility's failure to monitor and report the resident's bowel status and obtain necessary lab work highlights a significant lapse in care. The APNP and nursing staff did not adequately communicate or document the resident's condition, leading to a lack of timely intervention. The facility's policy on incontinence was not followed, as appropriate treatment to prevent infections and restore continence was not provided. This deficiency underscores the need for improved communication, documentation, and adherence to care plans to ensure resident safety and well-being.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, R4 and R5, who were at high risk for pressure injuries. R4, who was dependent on staff for bed mobility and had a high Braden Score indicating risk, developed a stage 3 pressure injury on her buttock and a Deep Tissue Injury (DTI) on her left heel. Despite these developments, the care plan was not revised to include necessary interventions such as offloading, turning, and repositioning. Initial assessments and measurements of the pressure injuries were not completed, and treatment was not immediately implemented. R5, who required maximal assistance for bed mobility, also developed a DTI on his right heel. Similar to R4, the facility did not implement care plan interventions for offloading, turning, and repositioning. There was no comprehensive assessment or measurements of R5's pressure injury, and documentation of the injury was lacking in the medical record. The facility's failure to document and assess the pressure injuries in a timely manner contributed to the deficiency. The facility's policy on pressure injury prevention was not followed, as evidenced by the lack of individualized interventions and documentation in the care plans for both residents. The facility's staff, including the wound care nurse, did not perform necessary assessments or implement physician-ordered treatments promptly. The facility's Director of Nursing acknowledged the issues with documentation and treatment, indicating that previous staff had not adhered to proper procedures, which led to the deficiencies identified by the surveyor.
Deficiency in QAPI Training for CNAs
Penalty
Summary
The facility failed to ensure that staff received the required annual Quality Assurance and Performance Improvement (QAPI) training, as evidenced by the lack of training documentation for 4 out of 5 Certified Nursing Assistants (CNAs) reviewed. The facility's policy mandates that training requirements be met annually and that the elements and goals of the facility's QAPI program be included in the training content. However, the surveyor found that the facility did not provide the necessary QAPI training to the majority of the CNAs reviewed, which could potentially affect all 69 residents in the facility. During the survey, the Director of Nursing (DON) acknowledged the issue, stating that a change in training software had occurred and that they did not have access to the previous system to verify training completion. Although the Nursing Home Administrator (NHA) later provided documentation confirming that other required trainings were completed, it was confirmed that only one CNA had completed the QAPI training. The facility was unable to provide documentation for the remaining four CNAs, indicating a deficiency in meeting the training requirements as per their policy.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure the accurate and safe administration of medication for a resident who was self-administering Entresto, a medication for heart failure, without proper assessment and authorization. The resident, who was admitted with a diagnosis of chronic heart failure, was documented as self-administering the medication from April 18, 2024, to May 3, 2024. However, there was no self-administration assessment completed, no physician's order for self-administration, and no care plan in place regarding the self-administration of medication. The facility's policy requires an interdisciplinary team assessment to determine if a resident can safely self-administer medication, along with a prescriber's order and documentation in the care plan. Despite these requirements, the resident's medication administration record indicated unsupervised self-administration without the necessary assessments or orders. The issue was identified by the facility, and the resident's medications were subsequently administered by the facility starting May 3, 2024. The deficiency was brought to the attention of the facility's administration during a surveyor's exit meeting.
Resident's Mail Privacy Breach
Penalty
Summary
The facility failed to ensure a resident's right to privacy was maintained when receiving mail. A resident, identified as R7, who was cognitively intact, reported that their mail was delivered opened. The incident involved a package that was opened by an LPN without the resident's permission. The Director of Nursing (DON) confirmed that the package was opened by the LPN after being instructed by a receptionist to ensure the contents were safe. The LPN was told by the receptionist that the resident had been ordering knives, which prompted the opening of the package. However, the package contained medication, and the LPN had to explain to the resident why the package was opened. The receptionist, when interviewed, denied instructing staff to open residents' mail. Despite this, the DON maintained that the receptionist had instructed the LPN to open the package. The facility's policy on communication and mail handling, dated 3/26/2023, states that residents' rights to send and receive mail should be protected, and mail should not be opened by staff. The incident was brought to the attention of the Nursing Home Administrator and the DON, but no additional information was provided as to why the facility did not ensure the resident's right to privacy was maintained.
Failure to Promptly Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to promptly investigate and resolve grievances for three residents, identified as R16, R17, and R18, during a survey. The facility's grievance policy mandates prompt resolution and communication with residents throughout the process, overseen by a designated Grievance Official. However, the surveyor found that grievances were not documented or investigated until prompted by the surveyor's inquiries. For R16, a grievance was noted during an abuse investigation, but the facility did not start investigating until after the surveyor's request, and the grievance remained unresolved. Similarly, R17's grievance was not addressed until the surveyor inquired about it. The resident had expressed concerns about a staff member's behavior and issues with call light responses. The facility's investigation summary did not address these specific concerns, and the grievance was not resolved. R18 also reported inappropriate behavior from a staff member during an abuse investigation, but the facility did not begin investigating until after the surveyor's inquiry, and the grievance remained unresolved. The surveyor noted that the facility's grievance process was not followed, as grievances were not promptly investigated or resolved, and documentation was incomplete. The facility's failure to adhere to its grievance policy resulted in unresolved grievances for the three residents, highlighting a deficiency in the facility's handling of resident concerns.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report two incidents of alleged abuse involving residents R10 and R3 to the State survey agency and/or Nursing Home Administrator within the required timeframe. In the first incident, an allegation of sexual assault involving R10 was not reported to the Administrator and the State agency immediately, but rather several hours after the allegation was made. R10, who has moderate cognitive impairment, reported the incident to Social Services, who then informed the Director of Nursing. However, the report to the State agency was delayed until later in the day, well beyond the required two-hour window. In the second incident, an allegation of physical abuse involving R3 was not reported to the State Survey agency within the required two-hour timeframe. R3 reported being physically mishandled by staff, but the facility did not submit the necessary documentation to the State agency until two days after the incident was discovered. The Director of Nursing was unable to provide an explanation for the delay, as the employee responsible for submitting the report was no longer employed at the facility. The facility's policy mandates that all alleged violations be reported to the appropriate authorities within specified timeframes, particularly when the allegations involve abuse or result in serious bodily injury. Despite this policy, the facility failed to adhere to these requirements in both cases, resulting in a deficiency noted by the surveyors.
Incomplete Investigations into Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse, misappropriation of property, and mistreatment for three residents. Resident R10, who has a moderate cognitive impairment, reported a sexual assault by a staff member. The facility's investigation was incomplete as it only included interviews with two staff members present during the alleged incident, leaving out other staff who were on duty that night. The Director of Nursing could not explain why the investigation was not comprehensive. Resident R15, who is cognitively intact, reported missing money and an incident where a CNA did not assist with toileting and behaved inappropriately. The facility's investigation did not include interviews with all relevant staff, including those who might have been present when the money went missing or who could have witnessed the interaction with the CNA. The Nursing Home Administrator acknowledged the lack of thoroughness in the investigation. Resident R11 alleged neglect, stating that a CNA refused care and threw bedding at her. The facility's investigation included resident statements but failed to ask staff if they had any knowledge of the incident. The Director of Nursing, who was not in her role at the time, indicated that staff should have been questioned about their awareness of the situation. The facility did not provide additional information to explain the incomplete investigation.
Failure to Document and Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R7, received necessary assistance with activities of daily living, specifically in maintaining good grooming and personal hygiene. R7, who was cognitively intact and required substantial assistance for bathing, did not have any documented showers from mid-April to mid-May 2024. Despite R7's expressed importance of choosing between different types of baths, the facility's records and interviews revealed a lack of documentation and execution of scheduled showers for R7. Interviews with facility staff, including a CNA and LPN, indicated that a new system for tracking showers was implemented in March due to previous issues with missed showers. However, the system failed to ensure R7 received weekly showers as scheduled. The LPN and DON were unable to provide any documentation proving that R7 received showers during the specified period, highlighting a breakdown in the facility's process for ensuring residents' hygiene needs were met.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of fall prevention interventions for a resident identified as R10. R10 has a medical history that includes hemiplegia and hemiparesis following a cerebral infarction, hypertension, and bilateral above-knee amputation. The resident's care plan, initiated on February 15, 2024, included specific interventions to prevent falls, such as ensuring the call light and personal items were within reach, maintaining a well-lit and clutter-free environment, and placing a body pillow on the side of the bed closest to the door. However, during multiple observations on June 26 and June 27, 2024, the surveyor noted that the body pillow was not present on the right side of R10's bed, which was closest to the door, and the call light was not consistently within reach. Despite the care plan's directives, the surveyor observed R10 in bed without the body pillow on the right side during several checks, and the call light was found on the floor on one occasion. When questioned, R10 indicated that the staff only sometimes placed a pillow alongside her. The LPN/Unit Manager confirmed that the interventions should have been in place according to the care plan. The Nursing Home Administrator and Director of Nursing were informed of these observations, but no explanation was provided for the failure to implement the fall prevention measures as outlined in R10's care plan.
Deficiency in Respiratory Care for Resident Using CPAP
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as R7, who required the use of a CPAP machine. The deficiency was noted during an interview and record review, where it was found that R7 did not have medical doctor (MD) orders documenting the settings or cleaning schedule for the CPAP machine, as required by the facility's policy. Additionally, R7's care plan did not address the use of the CPAP machine, despite the resident's diagnoses of Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Sleep Apnea. The hospital discharge summary for R7 indicated the continuation of PAP therapy at bedtime, but this was not reflected in the facility's documentation. The surveyor's investigation revealed that the facility typically receives CPAP orders before a resident's arrival, and the machine is set up with the correct settings at that time. However, in R7's case, there was no documentation in the Medication Administration Record (MAR) regarding the use, cleaning, or maintenance of the CPAP machine. During an interview, the LPN Unit Manager confirmed that residents using CPAP machines should have corresponding orders and care plans, which were absent for R7. The issue was brought to the attention of the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing during the exit meeting, but no additional information was provided to explain the oversight.
Significant Medication Errors Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that two residents, R8 and R9, were free from significant medication errors. R8, who had a kidney transplant, was prescribed Tacrolimus to prevent organ rejection. However, during the first five days of R8's admission, the resident missed six out of eleven doses due to the medication being unavailable. The facility's policy required staff to notify the pharmacy and the attending physician if medications were unavailable, but there was no specific policy on when to notify a provider after a resident missed medication. Interviews with staff revealed that the medication was not in the contingency supply, and there was a lack of documentation explaining the missed doses. R9, diagnosed with atrial fibrillation and heart failure, was prescribed Ivabradine. Between January 4 and January 9, 2024, R9 missed nine out of ten doses of the medication. Similar to R8's case, the medication was not available, and there was no documentation regarding the missed doses. Interviews with staff indicated that the facility had recently changed pharmacy providers due to previous issues with medication availability, but the new system had not yet resolved the problem for R9. The facility's Director of Nursing and Assistant Director of Nursing were unable to provide explanations for the missed doses for both residents. The surveyor noted that the facility's process for handling unavailable medications was inadequate, as there was no clear policy on notifying providers after missed doses, and the contingency supply did not include the necessary medications. The facility's failure to ensure the availability and administration of critical medications resulted in significant medication errors for both residents.
Inaccurate Medical Record Documentation for Resident with Amputations
Penalty
Summary
The facility failed to maintain accurate medical records for a resident identified as R10, who has a medical history of diabetes mellitus and bilateral above-knee amputations. Despite the resident's condition, the facility's records inaccurately documented that diabetic foot checks were being performed daily, as per a physician's order dated 4/4/24. This order required daily diabetic foot checks at bedtime, which were recorded as completed on the resident's medication administration records (MAR) for April, May, and June 2024. However, the resident does not have feet, making these documented checks impossible. The deficiency was identified during a surveyor's review of the resident's MAR and through interviews with facility staff. On 6/26/24, the surveyor observed the resident and confirmed the bilateral above-knee amputations. Interviews with a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) revealed that checks and initials on the MAR indicated that the treatment was performed. The DON acknowledged that the issue was supposed to have been corrected, yet the MAR continued to reflect the completion of diabetic foot checks as of June 25th, 2024.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 827 citations issued within 25 miles in the last 12 months — including the 24 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Southpointe | 0.8 mi | ★★★★★ | 19 | 0 |
| Maple Ridge Health Services | 1.8 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Greenfield | 1.8 mi | ★★★★★ | 5 | 1 |
| Sunrise Health Services | 2.3 mi | ★★★★★ | 1 | 0 |
| Complete Care At Hales Corners | 2.5 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Greendale Park Nursing And Rehab.
100% money-back within 48 hours.
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.