Below average — CMS composite of the measures below.
The next survey window likely opens around September 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 Ingleside Manor during CMS and state inspections, most recent first.
The facility failed to prevent and treat pressure injuries for two residents. One resident entered with existing PIs and later developed a worsening heel wound that progressed to a Stage IV PI with osteomyelitis after missed readmission skin assessment, incomplete wound measurements, lack of provider notification, poor offloading, and improper wound care practices. Another resident admitted without PIs later developed multiple unstageable wounds and cellulitis, with delayed care planning, infrequent Braden assessments, missed treatments, and missed weekly wound assessments.
The facility did not maintain an effective infection prevention and control program. Water management records showed only limited temperature logs, and the IP stated the documented locations were not all areas that should be monitored weekly. The Maintenance Director said he had not done temperature testing since starting and was unaware of prior documentation. The infection surveillance log listed residents on antibiotics and antivirals for sepsis, UTI, bacteremia, shingles, wound infection, pneumonia, and cellulitis, but it did not include symptom monitoring, and staff stated residents on antibiotics should have ongoing assessments and documentation.
Resident Council concerns were not acted on promptly when multiple residents reported that the facility phone was not being answered. Residents said they could not reach the front desk or staff when returning from appointments, contacting family, or trying to update the facility, and one resident reported calls being answered and then hung up. The ANHA acknowledged staffing gaps at the front desk, weekend calls going to the nurse stations or voicemail, and that he had reviewed the concerns but had not seen the minutes documenting them.
The facility did not ensure that 5 residents had current advance directive documentation or evidence of advance care planning beyond code status. Record review found no POAHC documents or documented discussions about establishing one for these residents, despite the facility policy requiring staff to inquire about advance directives on admission and document any offer of assistance and the resident's decision. ANHA C and the DON both confirmed that such discussions should have been documented.
A facility failed to maintain a safe, clean, and homelike environment in a shower room and one resident’s room. Surveyors found a large open hole in the shower floor, missing and broken tiles, exposed rusty metal, dust on the vent, and debris left in the shower drain for a week; the MD and ANHA acknowledged the conditions. Surveyors also observed a broken chair rail behind a resident’s bed with splinters and sharp edges, and the resident reported she had raised the concern weeks earlier.
A resident with a surgical wound had multiple ordered wound treatments missed or not completed, with MAR entries citing unavailable supplies, staffing, and time constraints, and a progress note describing an overwhelmed agency RN and a wound with purulent drainage and bloody discharge. In addition, three residents receiving antibiotics for UTI-related conditions did not have documented assessments or continued monitoring through the course of treatment, and the DON and IP stated assessments should be documented throughout antibiotic therapy.
Failure to Report Abuse Allegation Within Required Timeframe: A resident with MS and major depressive disorder had a family-reported abuse allegation involving rude, demeaning CNA behavior and improper care. The ANHA investigated and decided it was unsubstantiated, but the allegation was not reported to the state within the required 2 hours, despite the facility policy and later acknowledgment by the NHA and corporate consultant that abuse allegations must be reported within that timeframe.
A resident with a suprapubic catheter and a history of UTIs reported that staff reused catheter bags and did not always cleanse tubing ends. During observation, staff removed a bed bag containing urine and attached an old leg bag that also contained urine in the bag and tubing, while staff could not explain how long the bags had been in use or how they were being cleaned before reuse.
A resident on a vegetarian, no-dairy diet was not consistently provided protein alternatives or monitored for protein intake despite significant weight loss. Staff served meals without a meat replacement, did not document a specific nutrition intervention plan, and missed multiple weight and intake monitoring opportunities. The resident reported concern about not getting enough protein and identified several foods he would eat, while the RD and DM acknowledged that protein replacement and monitoring had not been addressed.
Medication error rates exceeded the allowed threshold when surveyors observed 4 errors in 31 opportunities. An LPN gave one resident an extra Senna Plus tablet, administered Simethicone without an order, and omitted ordered Miralax, while another resident received only 1 of 2 ordered Senna Plus tablets. The DON confirmed these were medication errors and that physician orders should be followed.
Medication storage and expiration dating were not followed when a medication tech left a stock bottle of Senna Plus, a stock bottle of AREDS, and a cup with one loose Senna Plus tablet on top of an unattended medication cart while administering meds in a resident’s room. Surveyors also found an open bottle of Milk of Magnesia on the cart that was expired, and the LPN and DON both stated it should not have been there.
A resident with cerebral infarction, DM2, and CHF had physician orders for a vegetarian, no-dairy diet and was cognitively intact, but the facility did not provide meat-free protein alternatives or document his likes and dislikes in the care plan. During observation, he said he was concerned about not getting enough protein and reported that staff had not offered substitutes such as PB&J, beans, tofu, or meat analogs. The DM and DON acknowledged the resident’s vegetarian needs were not addressed as expected, and the kitchen roster still listed milk for breakfast despite the resident’s no-meat, no-eggs, no-dairy preferences.
Hospice collaboration and communication were not established for a resident receiving hospice services. The resident had CHF and FTT and was enrolled in hospice, but the facility did not have the current hospice POC or visit notes available to staff, and pressure injury assessments and measurements were not in the chart until the surveyor requested them. The NHA acknowledged a documentation gap, and an RN stated there was no designated staff member to coordinate the hospice POC with the facility.
QAPI failed to identify and address pressure injury care deficiencies for two residents. One resident admitted with existing PIs had incomplete skin assessments, missed wound documentation, lack of provider notification, poor off-loading, and wound care cross contamination, and later developed an unstageable PI that progressed to stage IV with osteomyelitis. Another resident admitted without PIs developed multiple PIs that progressed to unstageable wounds, along with cellulitis, bacteremia, and osteomyelitis, while the care plan was delayed, Braden scoring was infrequent, and several wound treatments and weekly assessments were missed.
Failure to Offer Pneumococcal Vaccination: The facility did not ensure that all residents were offered pneumococcal immunization as required. Two residents reviewed were not offered PCV15, PCV20, or PCV21 despite vaccine histories showing one resident had prior PPSV23 doses and the other had no pneumococcal vaccine documentation. The IP stated both residents were not up to date and should have been offered vaccination at admission.
A resident with multiple comorbidities was admitted with an abdominal wound that was not comprehensively assessed according to professional standards. Initial and ongoing wound assessments were incomplete, lacking documentation of key characteristics such as drainage, odor, and changes in size. Despite the wound increasing in size and developing a foul odor, there was no timely physician notification. The resident's condition worsened, leading to hospital readmission with a wound infection and septic shock.
Multiple residents reported and were observed to have unclean rooms, including visible debris, dried spills, and fecal matter, with staff confirming that housekeeping was not performed regularly due to staffing shortages. Facility policy requiring regular cleaning was not consistently followed, and there was insufficient communication with residents about their housekeeping concerns.
Multiple residents did not receive medications as ordered due to issues such as internet outages, medication unavailability, and untimely administration by nursing staff. Facility policies requiring timely medication administration and error reporting were not consistently followed, resulting in missed and delayed doses for residents with complex medical needs.
A resident with multiple chronic conditions was not consistently allowed to eat in the dining room as per her documented preference, due to staff failing to coordinate her morning care and shower schedule. Despite her care plan and meal tickets indicating her choice, she was served breakfast in her room instead of the dining room, which was confirmed by interviews with the CNA, DM, and DON.
A resident with a stage 2 pressure injury and multiple comorbidities did not receive prescribed pressure ulcer prevention interventions, including use of a pulsating mattress, pressure-relieving cushion, and regular repositioning. Staff failed to ensure these interventions were in place, and the care guidance provided to CNAs did not include necessary pressure injury prevention measures.
A resident with a suprapubic catheter was observed with their catheter tubing and drainage bag resting on the floor, contrary to facility policy and care plan instructions. Both a CNA and the DON confirmed that catheter equipment should not be on the floor, and the resident expressed concern due to a history of UTIs.
The facility did not develop or implement care plans for two residents with significant behavioral health needs—one with a substance use disorder and another with a history of suicidal ideation and attempts. Staff failed to assess, monitor, or provide interventions for these conditions, and the facility lacked a substance abuse policy. Key staff were unaware of the residents' behavioral health issues, and no referrals or precautions were put in place.
Two residents did not receive critical prescribed medications, including seizure medications and insulin, due to issues such as internet outages and unavailable drugs. Facility staff did not follow established policies for medication administration, failed to use available contingency supplies, and did not effectively communicate alternative procedures, resulting in significant medication errors.
Multiple residents reported and were observed to be affected by flies and ants in their rooms and common areas, with flies landing on a resident during an interview and others using fly swatters or sticky strips to manage the issue. Despite the facility's pest control policy, staff and maintenance acknowledged ongoing pest problems and could not confirm an effective plan to address the infestation.
A resident with type 2 diabetes had blood glucose readings above the ordered threshold on two occasions, but the physician was not immediately notified as required by orders and facility policy. Nursing staff and the DON confirmed that notification and documentation should have occurred at the time of the events, but records showed no timely communication with the provider.
An LPN suspected that a nurse may have taken medication from the med cart after accessing it without proper oversight, but did not immediately report this suspicion to the DON or NHA as required by facility policy. The LPN acknowledged knowing the reporting requirement but failed to act, and the NHA confirmed that no report was made.
A resident with impaired mobility due to osteoarthritis did not receive or have documentation for the required number of showers, as only a fraction of scheduled showers were recorded. Facility staff confirmed that showers were to be documented and that missing documentation meant the care was not provided, resulting in a failure to meet the resident's needs for personal hygiene and skin assessment.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to follow the established care plan.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident did not receive sufficient food and fluids to maintain their health, as required. The facility failed to ensure the necessary provision of nutrition and hydration.
A resident with multiple medical conditions and moderate cognitive impairment was not seen by a physician within the required timeframe after admission, as only a nurse practitioner visit was documented. The DON confirmed that the resident did not receive the mandated physician visits according to facility policy and federal regulations.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
Staff failed to follow infection control protocols during wound care and perineal care for two residents. An LPN did not perform hand hygiene between glove changes while treating a resident with lower limb wounds, and a CNA placed used washcloths and a towel inappropriately after pericare, contaminating clean areas. Both incidents were acknowledged by staff as breaches of the facility's infection prevention policies.
The facility failed to provide adequate supervision and implement required safety interventions for several residents, including one who eloped without staff knowledge, two who smoked without proper assessments or care plans, one who voiced suicidal ideations without appropriate follow-up, and another at risk for falls without documented interventions. These deficiencies were identified through observations, interviews, and record reviews, revealing lapses in assessment, care planning, and staff communication.
A resident did not receive enough food and fluids to maintain their health, as surveyors found that the facility did not adequately meet the individual's nutritional and hydration needs.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices. The report does not specify the actions or omissions that led to this deficiency or provide details about the individuals involved.
The facility did not complete annual performance evaluations for all CNAs and failed to provide the required 12 hours of annual in-service education for several staff, as confirmed by record review and administrator interviews. Documentation showed incomplete evaluations and insufficient education hours for multiple CNAs, with no specific policy in place for in-service education.
The facility did not ensure its QAA Committee included all required members, such as the Medical Director, and failed to meet at least quarterly as mandated. Sign-in sheets and administrator interviews confirmed these lapses, potentially affecting all residents.
The facility did not report several incidents, including a resident elopement and two resident-to-resident altercations, to the State Agency as required. Staff interviews revealed inconsistent training and understanding of reporting procedures for abuse, neglect, and altercations.
Staff interviews revealed inconsistent training on handling resident-to-resident altercations. While a CNA reported receiving training on deescalation and reporting, an LPN stated she had not received such training. An RN indicated prior training and referenced posted materials and communication tools for tracking incidents. The administrator confirmed the need for thorough investigation of all alleged violations.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided as required.
The facility did not maintain complete and accurate medical records for several residents, including missing documentation of a resident's change in condition and death, lack of nursing follow-up after a resident expressed suicidal ideation, and failure to document a resident-to-resident altercation in both involved residents' records. These actions did not meet facility policy or professional standards for medical recordkeeping.
A resident with impaired mobility and no cognitive impairment fell and struck her head when a Hoyer lift sling ripped during a transfer performed by a CNA and the DON. The sling used had been brought with the resident from the hospital. The incident was not documented in the EMR, and staff were unsure if an incident report was completed, despite facility policy requiring safe transfer techniques and proper documentation.
A resident experienced a significant change in eating habits, which was not promptly communicated to hospice or her family. Despite facility policies requiring notification of such changes, staff failed to inform the appropriate parties in a timely manner. The resident, who had diagnoses including senile degeneration of the brain and was utilizing hospice services, was eventually sent to the emergency room after hospice was notified several days later.
A facility failed to report a resident-to-resident abuse allegation within the required two-hour timeframe. The incident involved two residents, one with metabolic encephalopathy and the other with dementia and anxiety. The abuse was reported by a family member via email, leading to a delay in notifying the administration and the State Agency. Staff members were informed of the incident on the night it occurred and reported it to the nurse, but the administration was not aware until the next day.
A facility failed to thoroughly investigate a resident-to-resident abuse allegation involving two residents with cognitive impairments. The investigation did not include interviews with staff on duty during the incident, and inconsistencies were found in the information gathered. The Assistant Administrator acknowledged the investigation's shortcomings, leading to a deficiency.
A resident experienced late or missed medication administrations, contrary to the facility's policy requiring medications to be given within one hour of the prescribed time. The resident, with conditions including pulmonary hypertension and hypertension, reported receiving medications late and occasionally not at all, leading to chest pain and the need for nitroglycerin. The DON confirmed the late administrations.
The facility failed to maintain a medication error rate below 5%, with surveyors observing a 64.28% error rate. Three residents received their medications more than an hour late, contrary to facility policy. Delays were due to staff being new, behind schedule, or pulled to other tasks. Staff interviews revealed issues with pharmacy delays and lack of access to contingency supplies, impacting timely medication administration.
A resident with a history of heart failure experienced a significant change in condition, including weight gain and increased fatigue, which was not properly assessed or reported by the facility staff. Despite symptoms such as elevated heart rate and increased oxygen needs, the physician was not notified in a timely manner, resulting in the resident's hospitalization for atrial flutter and acute decompensated heart failure.
Failure to Provide Pressure Injury Care and Prevent Worsening Wounds
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new pressure injuries from developing or worsening for 2 residents reviewed for pressure injuries. One resident was admitted with four Stage 1 pressure injuries, was at risk for further skin breakdown, and had significant comorbidities including idiopathic peripheral neuropathy, gait instability, generalized weakness, and later hospice enrollment. The record states the facility did not complete a readmission skin assessment, did not accurately complete all wound assessments and measurements, did not notify the provider of changes to the pressure injury, did not offload pressure, and did not follow standards of practice during wound care. That resident developed an unstageable heel pressure injury that later deteriorated to a Stage IV pressure injury with osteomyelitis. The resident’s documentation showed gaps in facility monitoring and wound management. After readmission from the hospital, the facility had no documentation of weekly pressure injury measurements and assessments for approximately 3 months until surveyors requested them, and hospice records were used to obtain the missing assessments. The wound progressed from a deep tissue injury to an unstageable heel wound with foul odor, slough, eschar, undermining, and drainage, and later to a Stage 4 pressure injury with probable bone involvement. Surveyors also observed the resident’s heels directly on a pillow and not floated during a dressing change, and the wound nurse used dirty gloves, dirty scissors, and poor hand hygiene practices while handling wound supplies and packing the wound. A second resident was admitted without pre-existing pressure injuries but later developed four unstageable pressure injuries and cellulitis requiring IV antibiotics. The resident’s initial pressure injury care plan was not implemented until months after admission and contained few pressure off-loading interventions. The resident had only two Braden Scale assessments since admission, despite the facility policy calling for assessment on readmission and at least quarterly. The record also showed missed wound treatments and missed weekly wound assessments. Surveyors documented that the resident’s heel wound was not consistently measured or assessed, and the wound nurse and DON acknowledged that readmission skin assessments, weekly measurements, heel offloading, and provider notification of wound changes were expected but not consistently completed.
Infection Prevention Program Lacked Water Monitoring and Symptom Surveillance
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. The deficiency involved the facility’s Water Management Program and infection surveillance process, with the census noted as 48 residents. The facility’s Legionella Water Management Program policy stated that the program included specific measures to control Legionella, acceptable control limits or parameters, a system to monitor those limits and the effectiveness of control measures, and documentation of the program. For the water management component, surveyors requested documentation of monitoring of control limits and were provided only a few temperature logs. The records included TELS reports from December 2024 and April 2025 and an Ingle Living Communities Water Temps document from April 2025. The temperatures recorded varied by location, including some readings at 140 F, 120 F, 113 F, 110 F, 109 F, 108 F, and 111 F. The Infection Preventionist stated that the April documents were the only logs found for 2025, that the locations listed were not all the areas that should be monitored, and that all locations should be monitored weekly for water safety. The Maintenance Director stated that the boiler water needed to be at 140 degrees, but he had not done any temperature testing since starting in September and was not aware of any documentation of testing prior to arrival. For infection surveillance, the August 2025 Infection Surveillance Log listed residents receiving antibiotics or antivirals for diagnoses including sepsis, acute cystitis with hematuria, bacteremia, shingles, wound infection, pneumonia, cellulitis, and urinary tract infection, but there was no documentation of symptom monitoring on the log. The surveyor requested documentation of symptom surveillance and none was provided. An RN stated that residents with new symptoms should be monitored with vital signs for 3 days and that progress notes should be written through the course of antibiotic treatment. The Infection Preventionist stated that the line lists provided were not the facility’s expectation and that a new program would be rolled out October 1. The DON later stated that signs and symptoms of infection should be monitored, that she and the Infection Preventionist reviewed residents and created an updated line list with symptoms, and that assessments should be documented through the course of antibiotic treatment.
Resident Council Phone Concerns Not Addressed Promptly
Penalty
Summary
The facility did not ensure grievances and recommendations discussed during Resident Council meetings were acted upon promptly for several residents, including concerns about the facility phone not being answered. The Resident Council policy stated that residents would have the opportunity to express concerns and that formal written responses would be requested with a deadline before the next council meeting. However, three months of Resident Council minutes showed repeated complaints that residents could not get through to the facility by phone, and the surveyor also heard similar concerns directly from residents during interviews. Resident Council minutes documented that one resident questioned whether anyone was at the front desk to answer the phone, another reported observing the phone ringing at the nurses’ station without anyone answering it, and a third raised concerns that people trying to call the facility could not reach anyone. During interviews, residents stated that calls to the facility often went unanswered when they were trying to return from appointments, notify the facility they were running late, or receive important information from family or outside providers. One resident reported being unable to contact the facility after an appointment and said someone answered and hung up, then no one answered on repeated attempts. Another resident said the phone was not answered during off-hours and weekends, and that this scared her because she could not get help through the call light or the phone. The Assistant Nursing Home Administrator acknowledged awareness of phone issues and stated that staffing gaps occurred after the receptionist’s early retirement, with CNAs filling in and a receptionist scheduled Monday through Friday from 8 a.m. to 8 p.m. He also stated that on weekends calls would go to the nurse stations and then voicemail if no nurse was present, and that nurses were expected to check voicemail throughout the shift. He further stated he reviewed Resident Council concerns monthly and delegated them, but he did not see the July and August minutes addressing the phone concerns. He also stated the facility had recently switched the answering system sound board because calls were not being transferred properly and that he had boxes of phones to disperse to nurses, but had not yet done so.
Missing Advance Directive Documentation
Penalty
Summary
The facility did not ensure residents' rights to request, refuse, or discontinue treatment and to formulate an advance directive for 5 of 18 residents reviewed for advance directives: R8, R7, R3, R26, and R67. Their charts did not contain current copies of advance directives and/or did not contain evidence of advance care planning beyond code status for a time when they may not be able to make their own health care decisions. The facility's Advance Directives policy states that, prior to or upon admission, the social services director or designee inquires about the existence of written advance directives and, if none exist, staff will offer assistance in establishing them, with nursing staff documenting the offer and the resident's decision to accept or decline assistance. During record review, the surveyor was unable to locate documentation of a Power of Attorney for Health Care (POAHC) for R8, R7, R3, R26, and R67, and could not find evidence of discussions with these residents about establishing one. For R7, ANHA C reviewed the chart and stated there was no document or note of discussion, and later confirmed there was no documentation of discussion for R8, R3, R26, and R67. ANHA C stated that advance directives are discussed at admission or admission care conference and that there should have been a progress note from social work documenting the discussion and the resident's decision. DON B also stated there should absolutely be a documented conversation with the resident upon admission and that the facility should be assisting as needed.
Unsafe and Unclean Shower Room and Broken Chair Rail
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment in the Whirlpool Shower Room. Surveyors observed an opening in the floor covered by a loose piece of tile and a board, which when moved revealed a very large open hole with previously used plumbing. The wall next to the shower had missing tiles with exposed rusty metal protruding from the wall, the shower floor had missing tiles, the area where the shower wall met the floor had a dark substance and broken, worn tiles, the vent above the shower was coated with dust, and a hairband remained in the shower drain for one week. During the observation, the Maintenance Director and Assistant Nursing Home Administrator acknowledged the conditions, stating the hole was not secure, the wall needed repair, the tiles needed repair, the area needed cleaning, the vent was dirty, and items in the shower needed to be picked up and cleaned. The deficiency also involved R67’s room. R67 was admitted with diagnoses including conversion disorder with seizures or convulsions and generalized anxiety disorder. Surveyors observed a broken wood chair rail behind the bed above the headboard, approximately 30 inches above the floor, with splinters and sharp ends exposed. The Maintenance Director and Assistant Nursing Home Administrator observed the broken chair rail and agreed it could cause potential injury. The Assistant Nursing Home Administrator stated he had become aware of the broken chair rail several days earlier when Life Safety brought it to his attention. R67 stated she had reported the broken chair rail weeks earlier when she moved into the room and described the room as being in shambles.
Missed wound care and lack of antibiotic monitoring documentation
Penalty
Summary
Facility staff did not provide care and treatment in accordance with professional standards of practice for a resident with a surgical wound. R51 was admitted with diagnoses including aggressive skin cancer, aftercare following surgery for neoplasm, severe protein-calorie malnutrition, adult failure to thrive, cognitive communication deficit, and an open wound of the left buttock. The resident was cognitively intact, and physician orders required wound care to the left thigh and left hip/buttock, including cleansing, dressings, packing, and securement, with treatments ordered daily or twice daily depending on the wound. The record showed multiple missed wound care treatments for R51. On several dates, the MAR documented that ordered wound care was not completed, with reasons including drug/item unavailable, patient load/staffing, not enough time in the shift for one nurse to complete the work, and no treatment documented on another date. A progress note also stated that an agency RN was overwhelmed and unable to get to the resident’s wound because of short staffing and too many patients, and when the wound was assessed it had moderate purulent drainage, bloody discharge, and surgical incisions that were wider and wetter than before. Facility staff also did not document assessments through the course of antibiotic treatment for three residents with changes in condition related to infection. R6 had acute pyelonephritis and was ordered sulfamethoxazole-trimethoprim for MDRO proteus; R23 had UTI and hydronephrosis with renal and ureteral calculous obstruction and was ordered sulfamethoxazole-trimethoprim; and R69 had cystitis and chronic kidney disease and was ordered cefdinir. The surveyor could not locate continued assessments or monitoring for symptoms of UTI or documentation through completion of the antibiotic courses for these residents.
Failure to Report Abuse Allegation Within Required Timeframe
Penalty
Summary
The facility did not ensure that an allegation of abuse involving R42 was reported immediately to the administrator and to the State Survey Agency within the required two hours. The facility policy stated that suspected abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately, and that immediately means within two hours for an allegation involving abuse or serious bodily injury. R42 was admitted with diagnoses including multiple sclerosis and major depressive disorder. On 9/20/25, R42’s family member reported that CNAs had entered the resident’s room in an aggressive manner, made rude and demeaning comments, told the resident that no one wanted to work with her because she was picky, and said they did not have time to move her between chairs and her wheelchair for lunch. The family member also reported that the resident had a bowel movement and was not cleaned properly in the front. The family member contacted the head of the board of the organization to report abuse, and the information was passed to the NHA and then to the ANHA. The ANHA arrived at the facility, spoke with R42, and described the resident’s statements as more of a conduct report than abuse, stating the CNAs were rude and not welcoming. The ANHA started an investigation but did not file a report with the state because the allegation was found unsubstantiated. The NHA and corporate consultant later acknowledged that an allegation of abuse must be reported to the state within two hours.
Improper Reuse of Catheter Bags and Inadequate Catheter Care
Penalty
Summary
The facility did not ensure appropriate catheter care and services to prevent UTIs for a resident with a suprapubic catheter. The resident had diagnoses including neuromuscular dysfunction of the bladder and urinary incontinence, and the care plan directed staff to keep the catheter system as closed as possible and manipulate tubing as little as possible during care. The resident reported concern about catheter care, stating that she had experienced several UTIs since admission, that the facility reused catheter bags without always cleansing them, and that staff did not always wash the ends of the tubing when reconnecting them. During observation, a CNA and an admissions nurse performed catheter care and removed the resident’s bed bag, which had urine in it, then attached an old leg bag that was taken from the resident’s bathroom and also contained a small amount of urine in the bag and tubing. The admissions nurse cleansed the end of the leg bag tubing with alcohol wipes, but the bed bag was hung in the bathroom with urine still noted in the tubing. When questioned, the staff indicated they did not know how long the bags had been in use, whether they should be dated, or the exact process for cleansing them before reuse. The admissions nurse later stated the leg bag should have been cleansed out and was not, and the nursing home administrator and director of nursing stated the expectation was to follow the facility policy.
Failure to Provide Protein-Appropriate Meals for a Vegetarian Resident
Penalty
Summary
The facility failed to ensure that a resident who was prescribed a vegetarian, no-dairy diet received enough food and fluids to maintain nutritional status. The resident was admitted with diagnoses including cerebral infarction, type 2 diabetes, and congestive heart failure, and his MDS showed a BIMS score of 15, indicating he was cognitively intact. His physician ordered a vegetarian diet with no dairy, and his care plan noted a goal to maintain weight, meet personal food and dining preferences, and avoid unfavorable nutrition outcomes, but no specific diet or dietary interventions were documented on the care plan. The resident’s weights showed significant loss after admission. The hospital discharge weight was 228.3 lbs, then facility weights documented 206.2 lbs, 209.2 lbs, and 192.6 lbs within the first 20 days, including a 22.1 lb loss in 10 days and a 35.7 lb loss in 20 days. The facility’s RD noted the admission weight may have been questionable and did not believe significant changes had occurred, despite estimating protein needs at 70-88 grams per day. The facility did not weigh the resident on admission and for 10 days thereafter, and meal intake documentation was inconsistent, with multiple dates missing from the record. Survey observation and interviews showed the resident was not being provided a protein source on his meal trays to match his vegetarian preferences. During lunch observation, the dietary aide served only sweet potato fries, mashed sweet potatoes, peas, and wax beans, and told the resident they knew he did not like meat. The resident stated he was concerned he was not getting enough protein and reported he would eat peanut butter and jelly sandwiches, bean burgers, beans, meat analogs, and tofu, but said no one had tried to find replacements for meat. The DM stated she knew he was vegetarian but did not know whether his protein intake was being monitored, and the RD stated she had not recommended replacements or tracked his protein intake. The resident was later offered a plant-based supplement and additional protein foods only after surveyor inquiry, and the facility documentation showed the resident had experienced a 16% weight loss in 3 months.
Medication Pass Errors Exceeded Allowed Rate
Penalty
Summary
The facility did not ensure that medication error rates remained below 5 percent. During observation, interview, and record review, surveyors identified 4 medication errors out of 31 opportunities, resulting in an error rate of 12.9%. The errors involved 2 residents, R16 and R54, during the medication pass task. R16 had diagnoses including constipation and hypothyroidism and had physician orders for Miralax 17 grams twice daily and Senna Plus 1 tablet twice daily. On the observed medication pass, LPN J administered 2 Senna Plus tablets and Simethicone 80 mg chewable without an order, and Miralax was not administered even though it was signed out on the MAR. R54 had a physician order for Senna Plus 2 tablets twice daily, but during observation LPN J administered only 1 tablet. The DON confirmed that giving the wrong dose, giving a medication without an order, and omitting an ordered medication were medication errors and stated that physician orders should be followed.
Medication Storage and Expiration Dating Deficiency
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when surveyors observed medications left on top of an unsupervised medication cart in the hallway while a medication tech was administering medications to a resident in a room with the door closed. The cart was out of sight for about 5 minutes, and the items left unattended included a stock bottle of Senna Plus, a stock bottle of AREDS (PreserVision), and a medication cup containing one loose Senna Plus tablet. The facility policy stated that medication carts must be kept closed and locked when out of sight and that no medications are to be kept on top of the cart. Surveyors also observed an open bottle of Milk of Magnesia on the medication cart with an expiration date of 7/2025. The medication tech stated the bottle was expired and should not have been in the cart. The DON stated that nurses and the DON check medication storage for expiration dates and that nurses should be checking medications in the cart, and she confirmed the outdated medication should not have been there. The facility policy stated that expired medications and medications retained longer than recommended should be stored separately until destroyed or returned, and that opened medications must follow manufacturer or supplier expiration guidance.
Failure to Provide Vegetarian Protein Alternatives
Penalty
Summary
The facility did not provide food that accommodated a resident’s preferences and did not provide appealing options of similar nutritive value when the resident declined the meal served. The deficiency involved one sampled resident who was known to be a vegetarian and who had physician’s orders for a vegetarian diet with no dairy. The resident’s care plan identified a goal to maintain nutritional status and meet personal food and dining preferences, but it did not document specific dietary interventions or the resident’s likes and dislikes. The resident was admitted with diagnoses including cerebral infarction, type 2 diabetes, and congestive heart failure, and his most recent BIMS score was 15, indicating he was cognitively intact. During observation in the dining room, the resident received a meal of vegetables and sweet potatoes, and he stated that he was a vegetarian and was concerned about not getting enough protein. He reported that he did not like fish, eggs, or dairy, but would eat items such as a peanut butter and jelly sandwich, bean burgers, beans, meat analogs, and tofu. He also stated that staff had not brought him substitutes since admission and that no one had tried to find replacements for meat. Interview and record review showed the Dietary Manager knew the resident was a vegetarian but did not know whether his protein intake was being monitored or tracked, and she stated she had not immediately addressed his dietary needs when he was admitted. She also stated she was unaware of plant-based supplements until she found one in the kitchen during the survey. The DON stated the resident’s preferences should be met and that he should not have to ask for alternatives. A later review of the kitchen diet roster showed the resident listed as having no meat, eggs, or dairy, but the beverage preferences list still included milk for breakfast.
Hospice Care Plan and Communication Not Available to Staff
Penalty
Summary
The facility did not ensure hospice collaboration and communication processes were established to maintain continuity of care between hospice and the facility for 1 resident receiving hospice services. R28 was re-admitted with diagnoses including chronic heart failure and failure to thrive and was enrolled in hospice services on 1/7/25. The facility did not have R28’s current hospice plan of care or hospice visit notes available to staff, and the facility did not have record of R28’s pressure injury assessments and measurements until the surveyor requested the information and the facility contacted hospice for it. The facility’s Hospice Program policy states that the facility is responsible for coordinating with hospice representatives, communicating with hospice providers, and obtaining the most recent hospice plan of care for each resident. During interview, the NHA stated there should be a current hospice plan of care and visit notes available for R28 and acknowledged a documentation gap. The hospice RN stated the plan of care is available to the facility and that visit notes may be entered into MatrixCare or faxed if wound care is involved. However, the facility RN stated she could not locate R28’s care plan in the binder on the nurse’s station bookshelf and stated that each hospice service is handled differently. The RN also stated there was no designated staff member to coordinate the plan of care with hospice.
QAPI Failure to Address Pressure Injury Deficiencies
Penalty
Summary
The facility failed to identify issues requiring QAPI activity and failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to pressure injury care and prevention for two residents. The QAPI policy and QAPI Plan stated that the committee reviews data, identifies high-risk or problem-prone areas, and develops corrective actions and performance improvement projects, but the report states that this process was not initiated or completed for the pressure injury concerns described. One resident was admitted with four stage 1 pressure injuries and had significant co-morbidities including idiopathic peripheral neuropathy, generalized weakness, and a fractured syloid process of the right radius. The facility failed to complete a readmission skin assessment, accurately complete weekly wound assessments and measurements, notify the provider of pressure injury changes, document turning and repositioning, offload pressure, and follow wound care standards of practice, including cross contamination during wound care. This resident developed an unstageable pressure injury that deteriorated to a stage IV pressure injury with osteomyelitis. A second resident was admitted without pre-existing pressure injuries and later developed multiple pressure injuries, including wounds on both heels and the left lateral foot/5th metatarsal that progressed from stage 2 to unstageable. The resident was also diagnosed with cellulitis requiring IV antibiotics, Group B strep bacteremia, and osteomyelitis of the left fifth metatarsal, with amputation noted as the only definitive recommended treatment. The resident’s initial pressure injury care plan was not put in place until several months after admission and contained few interventions for pressure reduction/off-loading, and only two Braden Scale assessments were completed since admission despite the expectation that they be completed on readmission and at least quarterly. Several wound treatments and weekly wound assessments were missed.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility did not ensure that each resident was offered a pneumococcal immunization unless medically contraindicated or already immunized. In a review of 5 residents, 2 residents were found not to have been offered pneumococcal vaccination. The facility’s Pneumococcal Vaccine policy states that residents are to be assessed prior to or upon admission for eligibility and, when indicated, offered the vaccine series within 30 days of admission unless medically contraindicated or the resident has completed the current recommended vaccine series. R9 was admitted to the facility and had a Preventive Health Care Report showing prior PPSV23 doses on 11/20/2017 and 6/10/2011. Per PneumoRecs VaxAdvisor, the CDC recommendation for the resident’s age group was one dose of PCV15, PCV20, or PCV21 at least 1 year after the last PPSV23 dose, but there was no documentation that this resident was offered PCV15, PCV20, or PCV21. R2 was admitted to the facility and had no documentation of pneumococcal vaccines in the Preventive Health Care Report. Per PneumoRecs VaxAdvisor, the CDC recommendation for the resident’s age group was one dose of PCV15, PCV20, or PCV21, but there was no documentation that this resident was offered any of those vaccines. The Infection Preventionist stated that PneumoRecs app was used to determine whether residents were up to date and acknowledged that both residents were not up to date and should have been offered vaccination at admission.
Failure to Complete Comprehensive Wound Assessments and Timely Physician Notification
Penalty
Summary
A resident was admitted to the facility with a wound on her left abdomen, along with other medical conditions including rheumatoid arthritis, type 2 diabetes with polyneuropathy, and heart failure. Upon admission, the wound was noted to have exudate and odor, but the initial assessment was performed by an LPN, which is not in accordance with the Wisconsin Nurse Practice Act that requires an RN to conduct assessments. There was no evidence that an RN reviewed or signed off on the LPN's observation, nor was there documentation that a provider was notified about the wound odor at that time. Throughout the resident's stay, the facility failed to complete ongoing comprehensive wound assessments as required by professional standards and facility policy. Documentation was inconsistent and incomplete, lacking critical wound characteristics such as type, bed description, surrounding tissue appearance, drainage, and odor. The wound increased in size and developed a foul odor, but there was no timely notification to the physician regarding these changes. Multiple staff interviews confirmed that changes such as increased wound size, odor, and drainage should have prompted provider notification, but this did not occur. The resident's condition deteriorated, with the wound developing thick, green/brown drainage, increased pain, and redness. Eventually, the resident requested to be sent to the emergency department, where she was diagnosed with a wound infection and septic shock. Hospital records confirmed the presence of multiple organisms in the wound culture. The lack of comprehensive wound assessment, failure to follow professional standards, and delayed physician notification directly contributed to the resident's readmission to the hospital with a serious wound infection.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for multiple residents, as evidenced by direct observations and resident interviews. Several rooms were found to be unclean, with one resident's room containing dried substances, crumbs, and what staff identified as fecal matter on the outside of the toilet that had reportedly been present for over a month. Additional observations included trash bags containing dirty linen and personal protective equipment left on the floor, and floors with visible debris and dried spills. Residents reported that housekeeping did not clean their rooms regularly, with some stating their rooms were cleaned only once a week or less frequently. Staff interviews confirmed the lack of regular cleaning, with a CNA acknowledging that not all rooms could be cleaned daily and the Housekeeping Supervisor citing insufficient staffing to complete all necessary cleaning tasks. The facility's own policy required regular cleaning and disinfection of resident rooms, but this was not consistently followed. There was also a lack of systematic communication with residents regarding their housekeeping concerns, as the Housekeeping Supervisor did not participate in resident council meetings to address such issues.
Failure to Provide Timely and Accurate Pharmaceutical Services
Penalty
Summary
The facility failed to ensure the provision of pharmaceutical services to meet the needs of multiple residents, resulting in missed, delayed, or omitted medication doses. For several residents, medications were not administered as ordered due to various reasons, including the facility's internet being down, medications being unavailable, and untimely administration by nursing staff. Facility policies required medications to be administered in a safe and timely manner, within one hour of the prescribed time, and for medication errors to be documented and reported. However, these policies were not consistently followed. One resident with multiple sclerosis, convulsions, major depressive disorder, and vitamin D deficiency did not receive scheduled medications at two different times because the facility's internet was down, and staff did not utilize available contingency plans such as printed MARs or alternative internet access. Another resident with rhabdomyolysis and traumatic ischemia of muscle also missed a scheduled dose for the same reason. Interviews with the DON and ADON confirmed that these omissions were considered medication errors and that staff were not fully aware of or did not implement alternative procedures during the internet outage. Additional deficiencies included a resident with metabolic encephalopathy, sepsis, diabetes, epilepsy, and other conditions who missed multiple doses of critical medications over several days due to drug unavailability, despite the facility having a contingency supply. Another resident with end stage renal disease and epilepsy did not receive several medications after returning from a hospital stay because orders were not promptly renewed and medications were not available for an extended period. Furthermore, a resident reported regularly receiving medications late, and review of MARs and staff interviews confirmed that morning medications were administered well outside the required time frame, constituting medication errors. These events demonstrate failures in medication acquisition, timely administration, and adherence to facility policy.
Failure to Honor Resident's Dining Location Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's stated preference to eat meals in the dining room, as required by both facility policy and federal regulations regarding resident rights. The resident, who has a history of multiple sclerosis, cerebral infarction, major depressive disorder, muscle weakness, and heart failure, expressed her desire to eat in the dining room for social interaction and because she had no suitable place to eat in her room. Despite her care plan and meal tickets indicating her preference for dining room meals, staff did not consistently facilitate this choice. On the morning in question, the resident was not taken to the dining room for breakfast due to a delay in her scheduled shower, resulting in her receiving her meal in her room instead. Interviews with facility staff, including the CNA, Dietary Manager, and DON, confirmed that the resident's preference to eat in the dining room was known and documented. The DON acknowledged that it is the resident's right to choose where to eat and that staff should honor this choice. However, the failure to coordinate care and ensure the resident was clean and dressed in time for breakfast led to her not being able to exercise her right to dine in the dining room as she wished.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including Multiple Sclerosis, cerebral infarction, major depressive disorder, muscle weakness, and heart failure, was not provided with appropriate pressure ulcer prevention and care as outlined in facility policy and physician orders. The resident, identified as being at risk for pressure injuries, had a stage 2 pressure injury to the coccyx. The care plan and physician orders specified the use of a pulsating mattress, a pressure offloading cushion when up in a chair, and repositioning every 30 minutes. However, during the survey, the resident was observed sitting in a recliner without a cushion, and the specialty mattress was set to static rather than pulsate. Staff did not encourage or assist the resident to reposition during the nearly hour-long observation period. Further review revealed that the Resident Profile sheet used by CNAs to guide care did not include any pressure injury prevention interventions, despite these being present in the care plan and physician orders. Interviews with CNAs and the DON confirmed that the necessary interventions were not being followed, and the DON acknowledged that the resident's pressure injury prevention devices were not in place as required. The lack of implementation and communication of pressure injury prevention measures directly contributed to the deficiency.
Catheter Bag Placement Deficiency
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter was observed with their catheter tubing and drainage bag resting on the floor while seated in a recliner. The resident expressed concern about the care of their catheter tubing and drainage bag, noting a history of urinary tract infections. Facility policy, physician orders, and the resident's care plan all specify that catheter tubing and drainage bags should not touch the floor to prevent infection. During interviews, both a CNA and the Director of Nursing confirmed that catheter tubing and drainage bags should not be placed on the floor, and acknowledged that the observed situation was not in accordance with facility protocols. The deficiency was based on direct observation, resident interview, and review of relevant documentation, all of which indicated that the required standard of care for catheter management was not maintained for this resident.
Failure to Provide Behavioral Health Care and Services for Residents with SUD and Suicidal History
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to ensure residents received the highest practicable mental and psychosocial well-being. Specifically, the facility did not create comprehensive assessments or care plans to address a substance use disorder (SUD) for one resident and failed to address a history of suicidal ideations and attempts for another resident. The surveyor found that the facility did not have a substance abuse policy, and the care plans for both residents lacked goals, interventions, and monitoring related to their behavioral health needs. One resident with a documented SUD, including alcohol and cocaine abuse, was admitted with multiple related diagnoses such as alcohol-induced chronic pancreatitis and end-stage renal disease. Despite evidence of ongoing alcohol consumption, including the discovery of empty vodka bottles in the resident's room and a missed dialysis session, the facility did not develop or implement a care plan addressing the resident's substance use, triggers, or associated behaviors. The social worker was unaware of the resident's SUD and no referral to the facility's substance use program was made, as referrals were only initiated with a physician or NP order, not based on active diagnoses. Another resident with a history of conversion disorder, PTSD, personality disorder, and multiple suicide attempts was not provided with a care plan addressing suicidal ideations or attempts. The care plan did not include any goals, interventions, or monitoring for suicide risk, despite the resident's extensive history of attempts, including recent overdoses and self-harm. Staff interviews confirmed that such histories should be care planned to inform monitoring and interventions, but this was not done, and no precautions or monitoring were in place for the resident's behavioral health needs.
Failure to Prevent Significant Medication Errors Due to System and Supply Issues
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two residents not receiving their prescribed medications as ordered. For one resident with a diagnosis of unspecified convulsions and a risk for seizures, two critical seizure medications, Lamictal and Levetiracetam, were not administered as scheduled due to the facility's internet being down. Documentation on the Medication Administration Record (MAR) indicated the medications were not given, with the reason cited as 'no internet.' Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that missing a medication dose for this reason is considered a medication error, and that alternative methods for accessing the MAR, such as making paper copies or using management's cell phone hotspots, were not effectively communicated or implemented at the time of the incident. Another resident, admitted with multiple complex diagnoses including metabolic encephalopathy, sepsis, acute respiratory failure, type 2 diabetes, epilepsy, hypertension, kidney transplant status, and hypothyroidism, did not receive several ordered medications over multiple days. These included anticonvulsants (Lacosamide and Levetiracetam), insulin, and an immunosuppressant (Mycophenolate). The MAR showed multiple instances where medications were not administered, with reasons such as 'drug/item unavailable' or left blank, indicating omission. The DON confirmed that these omissions were medication errors and that staff should have accessed contingency medication supplies, which were available for at least some of the missed medications. Facility policies required medications to be administered in accordance with prescriber orders and within specified timeframes, and mandated that medication errors be documented and reported. The events described show that these policies were not followed, resulting in significant medication errors for both residents. The failures included lack of timely administration, inadequate communication of contingency procedures, and failure to utilize available medication supplies.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in the presence of flies and ants in multiple areas, including the dining area, hallways, and resident rooms. Observations included flies landing on a resident's leg and foot during an interview, as well as reports from several residents about persistent fly infestations in their rooms and throughout the facility. Some residents reported that flies landed on their food during mealtimes, and others mentioned having to use fly swatters or sticky strips to manage the problem themselves. Ant strips covered with ants were also observed in one resident's room. Residents with varying degrees of cognitive impairment and intact cognition voiced concerns about the ongoing pest issues, with some stating they had reported the problem to staff but had not seen any improvement. Maintenance staff acknowledged awareness of the fly problem and indicated that pest control services were provided on a scheduled basis, but could not confirm any specific plan in place to address the current infestation. Facility records and staff interviews confirmed that the pest control program was not effectively implemented to prevent or address the presence of pests as required by policy.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify and consult with a resident's physician after significant changes in the resident's condition. Specifically, a resident with type 2 diabetes mellitus had blood glucose readings above the ordered parameter of 350 on two occasions. The physician's orders clearly stated that if blood sugar was greater than 350, the nurse should administer 5 units of insulin and call the medical doctor. Despite this, there was no documentation in the resident's progress notes indicating that the physician had been contacted regarding these elevated blood sugar levels. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for the physician to be notified and for this notification to be charted each time the blood sugar exceeded the specified threshold. Review of the resident's records showed no such documentation at the time of the events. A late entry was made the following day, indicating that the provider was informed of the previous day's elevated readings, but this was not done immediately as required by the physician's orders and facility policy.
Failure to Immediately Report Suspected Misappropriation of Medication
Penalty
Summary
A deficiency occurred when an LPN failed to immediately report a suspicion of misappropriation of medication as required by facility policy and state law. The incident began when a Registered Nurse/Infection Preventionist (RN/IP) requested and took the keys to the medication cart from the LPN, accessed the cart, and later stated they had found what they were looking for. The LPN, suspecting that medication may have been taken, performed a count of the narcotic medications and found the count to be correct, but noted that there was no way to verify the count of other medications. Despite suspecting possible misappropriation, the LPN did not report the concern to the Nursing Home Administrator (NHA) or Director of Nursing (DON) as required by facility policy. During interviews, the LPN acknowledged awareness of the requirement to report suspicions of misappropriation to the DON or NHA but admitted not doing so. The NHA confirmed that staff are expected to immediately report such suspicions and that no report had been made by the LPN regarding this incident. Facility policies reviewed by the surveyor clearly state that any suspicion of misappropriation must be reported immediately to the administrator and appropriate authorities for investigation.
Failure to Provide and Document Required Showering Assistance
Penalty
Summary
The facility failed to provide and document regular showering assistance for a resident who required help with activities of daily living due to impaired mobility from osteoarthritis. According to the facility's own policy, showers are to be given to promote cleanliness, comfort, and to observe skin condition, with specific documentation required for each shower, including date, time, staff involved, skin assessment, and resident tolerance. The resident was scheduled to receive showers twice weekly, but only six showers were documented over a period in which 23 should have occurred. Interviews with the DON, medical records staff, and a CNA confirmed that showers were to be documented on paper forms and uploaded into the electronic medical record. However, there were significant gaps in the documentation, and the DON acknowledged that if a shower was not documented, it was considered not done. The lack of documentation and the inability to provide records for the majority of scheduled showers indicated that the facility did not consistently provide or record the required showering assistance for the resident.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Ensure Timely Physician Visits After Admission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was seen by a physician at the required intervals following admission. According to facility policy and OBRA regulations, a resident must be seen by a physician within 30 days of admission, then at least every 30 days for the first 90 days, and every 60 days thereafter. Record review and staff interview revealed that a resident admitted with diagnoses including cellulitis of the left lower limb, chronic venous insufficiency, and edema, and with moderate cognitive impairment, was only seen by a nurse practitioner shortly after admission. There was no documentation that the resident was seen by a physician within the required 30-day period after admission. During an interview, the DON confirmed that the only documented visit for the resident since admission was by a nurse practitioner, and acknowledged that the resident had not been seen by a physician as required by policy and regulation. This failure to ensure timely physician visits was identified through both record review and staff interview.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
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 received a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Follow Infection Control Protocols During Wound and Perineal Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as evidenced by staff not adhering to established hand hygiene and perineal care protocols for two residents. During wound care for a resident with cellulitis, venous insufficiency, and edema, an LPN removed gloves five times and applied new gloves without performing hand hygiene between glove changes, contrary to facility policy and standard infection control practices. Both the LPN and the Director of Nursing acknowledged that hand hygiene should have been performed after glove removal and before donning new gloves, but it was not done during the observed procedure. In a separate incident, a CNA performing perineal care for another resident used two washcloths for cleaning and rinsing, then placed the used washcloths back into the wash basin and the used hand towel onto the resident's bedside table next to personal items. The CNA confirmed that these items were contaminated after use and should not have been placed back into the basin or on the bedside table. The facility's infection preventionist also confirmed that contaminated items should not be returned to clean areas or surfaces, indicating a breach in infection control practices during perineal care.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions for multiple residents, resulting in deficiencies related to accident hazards and resident safety. One resident, who was identified as an elopement risk upon admission and had a history of wandering, was not provided with necessary interventions such as a Wanderguard or increased supervision. This resident was able to leave the facility unnoticed and was found walking down a busy street by a staff member on break. There was no documentation of a full assessment, vital signs, or follow-up monitoring after the resident was returned to the facility. Two residents who were identified as smokers did not have smoking assessments or care plans in place, despite facility policy requiring such evaluations upon admission. Staff interviews confirmed that smoking assessments and care plans were expected but not completed. Both residents were observed smoking on multiple occasions, and staff described informal processes for supervising smoking, but there was no formal documentation or individualized planning to address their safety needs related to smoking. Another resident who voiced suicidal ideations did not have a trauma assessment or care plan for suicidal ideations, and there was no documentation of notification to the DON, provider, or family. Staff interviews revealed inconsistent understanding of the required procedures following suicidal statements, and the resident was placed on 1:1 supervision without clear documentation or follow-up. Additionally, a resident at risk for falls did not have fall interventions in place, and fall interventions were not present on CNA care cards or the resident's Kardex, despite being listed in the care plan. Staff were unclear about the current fall interventions, and there was a lack of consistent documentation and implementation of fall prevention measures.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The lack of appropriate provision of food and fluids resulted in a failure to support the resident's overall health status.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents or staff involved, were not provided in the report. No further information about the circumstances or individuals affected was included.
Failure to Complete Annual CNA Evaluations and Required In-Service Education
Penalty
Summary
The facility failed to complete annual performance evaluations for all nurse aides and did not provide the required 12 hours of annual in-service education for several staff members. Record review showed that none of the five nurse aides selected for evaluation had performance reviews completed every 12 months as required by facility policy. Additionally, four out of five nurse aides did not complete the mandated 12 hours of continuing education within the year, with documented hours ranging from 8.5 to 10 out of the required 12. The facility also lacked a specific policy or procedure addressing the required in-service education for nurse aides. Interviews with the Nursing Home Administrator confirmed that the required annual evaluations and education hours were not completed for the staff in question. The administrator acknowledged that each CNA should have a current evaluation and at least 12 hours of annual education, but records did not support compliance with these requirements. The deficiency was identified through both record review and staff interviews, with specific examples cited for each staff member involved.
Failure to Maintain Required QAA Committee Membership and Meeting Frequency
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee with the required membership and meeting frequency as outlined in its own policy and federal regulations. Specifically, the QAA Committee did not consistently include the Medical Director, who is a required member, during meetings held in June 2024 and July 2025. Additionally, the committee did not meet at least quarterly as required, with two meetings over the last four quarters not occurring within the appropriate timeframe. Review of sign-in sheets confirmed the absence of the Medical Director at the specified meetings, and there was no documentation to support that the Medical Director was informed of the meeting content in a manner consistent with policy requirements. The Nursing Home Administrator confirmed these deficiencies during an interview, acknowledging both the absence of the Medical Director at the required meetings and the failure to meet the quarterly meeting schedule. The facility's QAPI policy specifies the necessary committee members and meeting frequency, but records and interviews demonstrated that these requirements were not met. This deficiency has the potential to affect all 48 residents residing in the facility.
Failure to Timely Report Abuse, Neglect, and Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property were reported to the appropriate authorities within the required timeframes. Specifically, three out of five reportable incidents were not reported as mandated. One resident eloped from the facility, and two separate resident-to-resident altercations occurred, but none of these incidents were reported to the State Agency as required by regulations. Interviews with staff revealed inconsistencies in training and knowledge regarding the reporting and management of resident-to-resident altercations. While a CNA indicated awareness of the need to deescalate and report such incidents immediately, an LPN stated she had not received recent training on this topic. An RN reported having received training and posted relevant materials at a nurses' station, but also noted that further education was planned. These findings indicate that the facility did not consistently follow established procedures for timely reporting of incidents involving potential abuse or neglect.
Inconsistent Staff Training on Resident-to-Resident Altercations
Penalty
Summary
Surveyor interviews revealed inconsistent staff training regarding resident-to-resident altercations. A CNA reported having received training on deescalating and reporting such incidents, while an LPN stated she had not received any recent training on this topic. The LPN described her intended response to future altercations, which included separating residents and redirecting them, but this was not based on formal training. An RN indicated she had received training in the previous months and referenced a flow sheet on resident altercations posted at a nurses station, as well as the use of a 24-hour board to communicate resident behaviors and incidents between shifts. The Nursing Home Administrator confirmed that all alleged violations should be thoroughly investigated.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and agreed to by the resident, and that proper care was given to those with feeding tubes.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for multiple residents, as required by facility policy and professional standards. For one resident with Alzheimer's disease, seizures, and intellectual disabilities, there was no documentation in the medical record regarding a significant change in condition and subsequent death. Although staff interviews confirmed that the resident experienced a decline, was assessed by nursing staff, and emergency services were called, none of these events or the resident's passing were recorded in the medical record. Another resident who expressed suicidal ideations did not have appropriate nursing documentation following the incident. While progress notes indicated the resident made statements about self-harm and staff redirected her, there was no evidence of follow-up or nursing assessment documented in the medical record, despite facility policy requiring such documentation for suicide threats. Interviews with facility leadership confirmed that nursing documentation was expected in these circumstances. Additionally, the facility failed to document a resident-to-resident altercation in both involved residents' medical records. While one resident's progress notes described the altercation and staff intervention, the other resident's record contained no documentation of the incident, contrary to facility policy requiring incident documentation for all involved parties. These omissions resulted in incomplete medical records that did not accurately reflect the care provided or the residents' conditions.
Failure to Ensure Safe Transfer and Documentation After Hoyer Lift Fall
Penalty
Summary
A resident with a history of acute respiratory failure and impaired physical mobility, who was assessed as cognitively intact, was involved in a transfer incident using a Hoyer lift. The care plan specified that two staff members and a Hoyer lift were required for transfers. During a transfer performed by a CNA and the Director of Nursing, the sling being used—brought with the resident upon readmission from the hospital—ripped, causing the resident to fall to the floor and strike her head. The resident was subsequently sent to the hospital, where no intracranial injuries or fractures were found. The incident was not documented in the electronic medical record, and there was uncertainty among staff regarding whether an incident report or progress note was completed. The facility's policy required the use of appropriate techniques and equipment to ensure resident safety, but the use of a potentially unsuitable sling and lack of documentation following the incident indicated a failure to follow established procedures. The administrator at the time of the survey was unable to locate any records or documentation related to the event.
Failure to Notify Hospice and Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify hospice and the resident's representative in a timely manner regarding a change in condition for one of the sampled residents, identified as R4. R4 experienced a change in her eating habits, which was not communicated to hospice or her representative. The facility's policy requires direct care staff to recognize and communicate significant changes in a resident's condition, such as a decrease in food intake, to the nurse. However, this protocol was not followed, leading to a delay in notifying the appropriate parties. R4 was admitted to the facility with diagnoses including senile degeneration of the brain, aphasia, and dysphagia, and was utilizing hospice services. Her care plan included monitoring food and fluid intake and notifying hospice of any changes in her condition. Despite this, R4's electronic medical record showed no meal intakes documented except for minimal amounts on specific dates. Staff reported that R4 had been unable to eat or drink for two to three days, but this information was not promptly communicated to hospice or her family member, who was her emergency contact. Interviews with facility staff revealed that there was a lack of communication regarding R4's condition. A Certified Occupational Therapy Assistant and a Certified Nurse Aide both noted R4's unusual refusal to eat, which was a significant change from her normal behavior. The Director of Nursing stated that hospice and family should be notified within a day if a resident is not eating or drinking, but questioned the accuracy of the information passed along by staff. Ultimately, hospice was only contacted after several days, and R4 was sent to the emergency room following the delayed notification.
Delayed Reporting of Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report a resident-to-resident abuse allegation within the required two-hour timeframe, as per their policy. The incident involved two residents, one with metabolic encephalopathy and the other with dementia and anxiety. The abuse was reported by a family member via email to the facility's former Admissions Director, who then informed the administration the following day. The incident was initially believed to involve a staff member, but upon investigation, it was found to be between two residents. The facility's policy requires immediate reporting of abuse allegations, defined as within two hours, but the report to the State Agency was delayed. The incident occurred when one resident allegedly backhanded another in the face and rammed her wheelchair into the other's wheelchair. The resident who reported the incident had moderately impaired cognition, while the alleged perpetrator had severely impaired cognition. Staff members, including CNAs, were informed of the incident on the night it occurred and reported it to the nurse on duty. However, the administration was not aware of the incident until the email was read the next day, leading to a delay in reporting to the State Agency. The Assistant Administrator was not involved in the initial reporting process and was unaware of the staff's immediate reporting to the nurse.
Inadequate Investigation of Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged resident-to-resident abuse incident involving two residents. The facility's policy requires that all allegations be thoroughly investigated, including interviewing all staff members who had contact with the residents during the period of the alleged incident. However, the investigation did not include interviews with staff who were on duty during the shift when the incident occurred. The Assistant Administrator confirmed that the investigation was not thorough and acknowledged that not all relevant staff were interviewed. The incident involved two residents, one with moderately impaired cognition and the other with severely impaired cognition. The alleged incident occurred when one resident reportedly backhanded the other in the face and rammed her wheelchair into the other's wheelchair. The resident who reported the incident informed the nurse on duty, who addressed the situation. However, the investigation did not verify if all potential witnesses, including a specific agency staff member, were contacted. Interviews conducted during the investigation revealed inconsistencies and gaps in the information gathered. Some staff members reported hearing about the incident secondhand, while others did not witness the event but were aware of the residents' behaviors. The Assistant Administrator admitted to limited involvement in the investigation and could not confirm if all necessary interviews were conducted. The facility's failure to interview all relevant staff and thoroughly document the investigation led to the deficiency.
Medication Administration Deficiency for a Resident
Penalty
Summary
The facility failed to administer medications as scheduled for a resident, identified as R3, who was reviewed for medication administration. R3's medications were documented as not being administered or being administered late on multiple occasions. The facility's policy requires medications to be administered within one hour of their prescribed time, but this was not adhered to. R3, who had diagnoses including pulmonary hypertension, hypertension, and localized edema, experienced late administration of several medications, including hydralazine, fexofenadine, liothyronine, losartan, torsemide, and folic acid, over the course of several days. R3 reported receiving medications late or not at all, recalling specific issues on certain dates where medications scheduled for 8:00 AM were administered as late as 12:30 PM. The resident also reported experiencing chest pain and needing to request nitroglycerin when blood pressure medications were not given on time. The Director of Nursing confirmed the late medication administrations and stated the expectation that medications should be administered within an hour of the scheduled time.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by a 64.28% error rate observed during a medication administration task. Surveyors noted 18 errors out of 28 medication opportunities, affecting three residents. The errors primarily involved administering medications more than an hour past their scheduled time, contrary to the facility's policy that medications should be administered within one hour of their prescribed time unless otherwise specified. Resident 10, who has multiple diagnoses including end-stage renal disease and hypertension, received her 8:00 AM medications at 9:09 AM. The delay was attributed to RN3, who was new to the facility and behind on her medication pass due to residents lining up and talking at the medication cart. Similarly, Resident 11, with diabetes and myopathy, received her 8:00 AM medications at 9:47 AM, after she had already finished breakfast. CNA1, who administered the medications, was observed giving insulin and a lidocaine patch without a breakfast tray present. Resident 12, diagnosed with heart failure and pulmonary hypertension, received her 8:00 AM medications at 10:10 AM, except for lorazepam and bupropion, which she refused. CNA1 reported starting late and being pulled to other tasks, contributing to the delay. Interviews with staff revealed issues such as lack of access to the facility's contingency supply, out-of-town pharmacy delays, and other tasks like falls and lab draws interfering with timely medication administration. The Director of Nursing confirmed the expectation for medications to be administered within the specified time frame, acknowledging the late administrations.
Failure to Monitor and Report Change in Condition Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care to prevent hospitalization, as per professional standards of practice. The resident, identified as R18, experienced a change in condition that was not fully assessed or monitored by the facility staff. Despite R18's history of congestive heart failure and other significant health issues, the facility did not complete necessary assessments or notify the physician of the resident's condition changes, including a significant weight gain and increased fatigue. R18 was readmitted to the facility with diagnoses including decompensated heart failure. The resident's weight increased by 12 pounds within a day, yet there was no documentation of the provider being updated or an assessment being completed regarding this weight gain. Additionally, the resident exhibited symptoms such as increased fatigue, elevated heart rate, increased respirations, and changes in oxygen needs, but these were not communicated to the physician in a timely manner. The facility's failure to act on these changes resulted in R18 being hospitalized with conditions including atrial flutter and acute decompensated heart failure. Interviews with facility staff, including the Nurse Practitioner and Director of Nursing, revealed that the facility's processes for monitoring and reporting changes in condition were not followed. The staff did not notify the provider of R18's weight gain or changes in vital signs, and the nurse responsible for R18's care did not attend the educational sessions provided by the facility on change in condition and physician notification. This lack of adherence to protocols and communication led to the resident's hospitalization, highlighting a deficiency in the facility's care practices.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 246 citations issued within 25 miles in the last 12 months — including the 6 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mount Horeb
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heartland Country Village | 8.8 mi | — | 0 | 0 |
| Four Winds Manor | 10.2 mi | ★★★★★ | 25 | 0 |
| Badger Prairie Hcc | 10.4 mi | ★★★★★ | 9 | 0 |
| Complete Care At Maple Grove Llc | 11.6 mi | ★★★★★ | 0 | 0 |
| Hebron Oaks | 11.7 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.