Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeland Health Care Ctr during CMS and state inspections, most recent first.
A resident with a suprapubic catheter, diabetes, CKD, and a hx of UTIs had the catheter collection bag clipped to a garbage receptacle while seated in a recliner, with the bottom of the bag resting on the floor and no privacy cover in place. The CNA said he used the garbage receptacle because the resident had detached the bag from the recliner before, while the DON stated the bag should be off the floor and that clipping it to a garbage receptacle was not acceptable.
A resident with dementia and a history of aggressive behaviors did not have a behavior care plan or individualized interventions developed, despite repeated incidents of agitation and physical aggression. During an episode of resistive behavior, a nurse yelled at the resident, physically restrained and shook the resident, causing the resident to feel afraid. The facility failed to notify the provider in a timely manner and did not follow its own policies for managing challenging behaviors, leading to substantiated abuse.
A resident with dementia and depression exhibited ongoing aggressive and resistive behaviors, but staff did not develop or implement a behavior care plan or consistently notify the MD as required. Despite repeated incidents of agitation and aggression, no individualized interventions were added for over three months, and staff lacked clear guidance. The situation escalated to an incident where a nurse yelled at and physically restrained the resident, resulting in the resident expressing fear of staff.
A resident with multiple medical conditions was given medications not prescribed to them by a nurse, leading to an emergency room visit. The incident was not reported to the Administrator or DON within the required timeframe, and only nursing staff had received education on abuse and neglect reporting, while other departments had not.
A resident with multiple medical conditions and intact cognition was given three medications by an RN that were not prescribed, after the RN stated to a CNA that the medications would help the resident sleep. The resident became lethargic and combative, requiring transfer to the ER for evaluation and IV fluids. The surveyor confirmed there were no physician orders for the administered medications.
A resident with dementia was left unattended on a toilet for over 3 hours by a CNA, who failed to complete the resident's care and transfer her back to bed. The resident, unable to communicate effectively, was found upset and cold by a night shift nurse. The facility confirmed the neglect, and the CNA involved no longer works there. Despite the incident, the resident showed no apparent emotional distress afterward.
The facility failed to report two abuse allegations involving multiple residents to the NHA and State Survey Agency in a timely manner. One incident involved a resident verbally abusing others, which was not reported immediately, and another involved a resident's mistreatment allegation against a CNA, delayed due to an LPN's belief of no issue. These lapses highlight deficiencies in the facility's internal reporting procedures.
Two residents experienced deficiencies in care due to the facility's failure to implement fall prevention interventions and post-fall protocols. One resident sustained a head injury that was not assessed or reported for three days, while another resident fell after being left unsupervised in the bathroom, contrary to their care plan. These incidents highlight lapses in adherence to safety protocols and individualized care plans.
Two residents were not treated with dignity during meals as a staff member stood while feeding them, contrary to facility policy. One resident, with dementia, was not given verbal cues or appropriately sized food, while another, dependent on staff for eating, did not receive the correct clothing protector. The staff member also used an undocumented nickname for one resident, further compromising dignity.
A resident with cognitive and heart conditions experienced a significant weight loss due to the facility's failure to consistently monitor their weight as per physician's orders. The resident's weight was not checked on multiple scheduled dates, leading to a 7.6-pound loss over 10 days, which was not reported to the physician until four days later. The facility acknowledged the resident's occasional refusal of care but only implemented a care plan for refusals on the day of the surveyor's exit meeting.
A facility failed to properly disinfect a resident's glucometer after use, as observed by a surveyor. An LPN used the glucometer for blood glucose testing and returned it to a plastic bag without cleaning it with a disinfectant effective against blood-borne pathogens. Interviews with staff revealed inconsistencies in disinfection procedures, with some using alcohol prep wipes, which are inadequate for this purpose. The surveyor noted the absence of appropriate disinfectant wipes on the medication cart.
Infection Control Failure With Catheter Bag Placement
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for one resident with a suprapubic catheter. The resident had diagnoses including diabetes, chronic kidney disease, retention of urine, neuromuscular dysfunction of the bladder, and a history of urinary tract infections. The resident’s care plan directed that the drainage bag be kept below the level of the bladder and included catheter care interventions such as cleaning the bag, storing the bag when not in use, and monitoring for signs of infection. On 01/20/26, a surveyor observed a CNA transferring the resident from a wheelchair to a recliner using a full body lift. During the transfer, the CNA attached the resident’s catheter collection bag to the resident’s garbage receptacle, and the bottom of the bag was resting directly on the floor. There was no privacy cover over the catheter collection bag. The same condition was observed again later that day and again on 01/21/26, with the catheter collection bag still attached to the garbage receptacle and the bottom of the bag resting on the floor without a privacy cover. During interview, the CNA stated he attached the bag to the garbage receptacle because the resident had detached it from the recliner before, and he felt it was the best option. The DON stated the catheter collection bag needs to be off the floor and that it is not acceptable to clip a catheter collection bag onto a garbage receptacle. The surveyor notified the DON and NHA of the infection control concern, and the DON stated the infection control and catheter policy was in the process of being updated to address where to hang a catheter collection bag while residents are in recliners.
Failure to Protect Resident from Physical and Verbal Abuse Due to Lack of Behavior Care Planning
Penalty
Summary
A resident with dementia, major depressive disorder, and osteoarthritis was admitted to the facility and began exhibiting aggressive and resistive behaviors within the first two weeks. Despite multiple documented incidents of physical aggression, agitation, and refusals of care over several months, the facility failed to develop or implement a behavior care plan with individualized interventions to guide staff in managing these behaviors. The resident's medical provider was not consistently notified of the increased behaviors, and there was no documentation of timely follow-up when the provider did not respond to staff communications regarding the resident's condition. On one occasion, the resident became agitated and resistive during care. A CNA attempted to calm the resident, but a registered nurse entered the room, yelled at the resident, and physically handled the resident by grabbing and throwing the resident's legs into bed, restraining the resident with a blanket, and shaking the resident's shoulders while yelling in the resident's face. The resident reported feeling afraid during this interaction. Staff interviews revealed that the nurse involved had a known history of stress-related outbursts, though not previously directed at residents. The incident was witnessed by another staff member, who intervened and reported the abuse immediately. The facility's policy required monitoring for staff burnout and the development of care plans for residents with challenging behaviors, especially those with cognitive deficits. However, the facility did not initiate a behavior care plan for the resident despite repeated aggressive incidents, nor did it ensure timely communication with the resident's provider. This lack of appropriate planning and intervention contributed to an environment where a staff member engaged in physical and verbal abuse of a vulnerable resident, resulting in a finding of immediate jeopardy.
Removal Plan
- All staff education on verbal and physical abuse.
- All staff education on resident's rights including: Freedom from mistreatment, Freedom from physical restraints, Treatment options (including the right of the resident to refuse care or treatment), Self-determinations (including the right of the resident to make decisions relating to care), and the Right of the Resident to be treated with courtesy and respect.
- All staff meeting which included additional abuse training, as well as burnout and stress management of staff. Staff not in attendance had the training available online to view.
- Audit included check-ins with residents to cover any resident concerns. Audits will continue.
- Audit included check-ins with staff to cover abuse, and staff stressors. Audits will continue.
- Grievance audit included facility staff reviewing resident grievances each weekday. Staff to audit for any area of concern related to abuse or misconduct.
- Staff interviewed other residents in the facility.
- Police were notified.
Failure to Provide Individualized Dementia Care and Timely MD Notification
Penalty
Summary
A resident with a diagnosis of dementia and major depressive disorder began exhibiting aggressive and resistive behaviors within the first two weeks of admission. Despite multiple documented incidents of physical aggression, agitation, and refusals of care over several months, the facility failed to develop or implement a behavior care plan with resident-specific interventions to guide staff in managing these behaviors. The facility also did not consistently notify the resident's medical doctor (MD) of the increased and ongoing behavioral issues, as required by facility policy. Documentation shows that staff were aware of the behaviors, but no individualized behavioral interventions were added to the care plan until more than three months after the behaviors began. Throughout the resident's stay, staff documented several episodes where the resident was physically aggressive toward CNAs, refused care, and became agitated, particularly during nighttime hours. Despite these repeated incidents, there was no evidence that the interdisciplinary team discussed these behaviors in their behavior management meetings, nor was there documentation that the MD was informed in a timely manner. When staff did attempt to notify the MD via fax about the resident's escalating behaviors, there was no follow-up when the MD did not respond over the weekend, and the issue was not addressed until days later. The lack of timely communication and absence of a comprehensive, individualized care plan left staff without clear guidance on how to manage the resident's challenging behaviors. The situation escalated when a staff member, in response to the resident's agitation and resistance, yelled at the resident, physically restrained them by holding their shoulders down and shaking them, and used a blanket to restrain the resident in bed. This incident was witnessed by another staff member, reported to management, and resulted in the resident expressing fear of staff during subsequent interviews. The facility's failure to provide appropriate treatment and services, including the development and implementation of a behavior care plan and timely communication with the MD, directly contributed to the continuation and escalation of the resident's challenging behaviors, culminating in an incident of staff-to-resident abuse.
Failure to Timely Report Potential Abuse/Neglect After Medication Error
Penalty
Summary
Facility staff failed to report an incident of potential abuse or neglect within the required timeframe after a resident received medications not prescribed to them, resulting in the resident being sent to the emergency room. The incident involved a registered nurse administering three medications—tizanidine, cyclobenzaprine, and diphenhydramine—belonging to another resident, with documentation indicating that the nurse was aware these medications were not ordered for the resident. The facility's policy requires immediate reporting of suspected abuse or neglect to the Administrator and Director of Nursing, but this was not followed, as the incident was not reported to the appropriate authorities within the mandated two-hour window. Record review and staff interviews revealed that only nursing staff received education on abuse and neglect reporting, while other departments such as food service and housekeeping had not received recent training on these requirements. The Director of Nursing confirmed that the lack of timely reporting was due to nursing staff not notifying leadership as required, and acknowledged that all staff should be included in abuse and neglect reporting education. The surveyor found no evidence of education provided to non-nursing departments regarding these reporting obligations.
Resident Administered Unprescribed Medications Resulting in Hospital Transfer
Penalty
Summary
A resident with diagnoses including heart failure, renal insufficiency, dementia, and paroxysmal atrial fibrillation was admitted with intact cognition, as indicated by a BIMS score of 13. During the night shift, a registered nurse administered three medications—Tizanidine, Cyclobenzaprine, and Diphenhydramine—that were not prescribed for the resident. Documentation from a certified nursing assistant indicated that the nurse acknowledged the resident did not have orders for these medications but stated they would help the resident sleep. The resident's medical record did not contain any physician orders for these medications. Following the administration of the unprescribed medications, the resident became increasingly lethargic, difficult to arouse, and combative with care, which was a change from their baseline. The resident was subsequently sent to the emergency department for evaluation, where laboratory tests and intravenous fluids were administered. The incident was reported to facility leadership, and the surveyor confirmed that the medications given were not ordered for the resident. No additional information was provided regarding the administration of these medications.
Resident Left Unattended on Toilet for Extended Period
Penalty
Summary
The deficiency involved a resident, identified as R61, who was left unattended on a toilet for an extended period of time, approximately 3 hours and 15 minutes, by a certified nursing assistant (CNA) during the second shift. R61, who has a diagnosis of dementia and is unable to make her needs known, required extensive assistance for toileting and was dependent on staff for transfers. On the evening of the incident, the CNA used an EZ stand to transfer R61 to the toilet but failed to complete the resident's care and transfer her back to bed before leaving at the end of the shift. The night shift nurse discovered R61 still seated on the toilet, visibly upset, and with extremities cold to the touch. Although R61 was unable to verbalize her distress, she was found saying the word "puta" repeatedly. A skin assessment revealed no immediate skin integrity issues, but bruises on the calves were noted later. The facility's investigation confirmed the neglect, and the CNA involved no longer works at the facility. R61's medical history includes dementia, major depressive disorder, muscle weakness, and anxiety, with severe cognitive impairments affecting daily decision-making. The resident's care plan explicitly stated not to leave her unattended in the bathroom, highlighting a clear breach of protocol. Despite the incident, subsequent monitoring showed no apparent emotional distress or changes in mood or behavior, and the resident was reported to be settled and pleasant following the event.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report two allegations of abuse involving five residents to the Nursing Home Administrator (NHA) and the State Survey Agency in a timely manner. The first incident involved a resident, R32, who was documented by RN-Q as verbally abusing other residents, R12, R62, and R27, on multiple occasions. These incidents were not reported immediately to the NHA as required by the facility's policy. The abuse was only discovered during a review of medical records by the facility, indicating a lapse in the internal reporting process. The second incident involved a resident, R39, who reported an allegation of mistreatment by a CNA. This allegation was not reported to the NHA until several days later, despite the facility's policy requiring immediate reporting. The delay in reporting was due to LPN-H's belief that there was no issue, as R39 appeared fine after discussing the situation. However, the facility's investigation later confirmed that the alleged CNA had worked with R39 on the date of the incident, contradicting LPN-H's initial assessment. Both incidents highlight a failure in the facility's internal reporting procedures, as staff did not adhere to the established policy of immediate reporting of abuse allegations. This failure to report in a timely manner is a significant deficiency, as it potentially compromised the safety and well-being of the residents involved.
Failure to Implement Fall Prevention and Post-Fall Protocols
Penalty
Summary
The facility failed to implement fall prevention interventions and did not consult with a physician post-fall for two residents, leading to deficiencies in care. One resident, identified as R72, sustained an injury of unknown origin to their scalp, which was not properly assessed or reported to a physician until three days later. Despite the resident reporting to a CNA that they had bumped their head on a cabinet, the LPN did not conduct a visual examination or initiate neurological checks. The facility's protocol for head injuries, which includes conducting neurological checks every shift for three days, was not followed. Another resident, R32, experienced an unwitnessed fall from the toilet due to being left unsupervised in the bathroom, contrary to their comprehensive care plan, which specifies that they should not be left alone on the toilet. R32 has a history of Alzheimer's Disease, dementia, and repeated falls, and requires substantial assistance for mobility and transfers. Despite these needs, the resident was left unattended, leading to a fall when they attempted to self-transfer from the toilet to their wheelchair. The facility's failure to adhere to established care plans and protocols for fall prevention and post-fall assessment resulted in these incidents. The lack of immediate assessment and monitoring for R72's head injury and the failure to supervise R32 in the bathroom as per their care plan highlight significant lapses in the facility's adherence to safety protocols and individualized care plans.
Failure to Maintain Resident Dignity During Meals
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect during meal times, as observed by the surveyor. Two residents, identified as R30 and R55, were fed breakfast simultaneously by a Recreation Therapy Leader (RTL-E) who was standing throughout the meal. This action was contrary to the facility's policy, which requires staff to be seated while assisting residents with meals to promote a dignified dining experience. Additionally, RTL-E referred to R30 by a nickname not documented in the care plan, further compromising the resident's dignity. R30, who has a history of vascular dementia, Alzheimer's disease, and other conditions, requires partial assistance with meals. The care plan for R30 specifies the use of a lipped plate with a Dycem and encourages the resident to eat slowly with verbal cues. However, RTL-E did not follow these instructions, as R30 was not informed of the food placement using clock descriptors, and the Dycem was missing. Furthermore, RTL-E fed R30 large pieces of bacon, contrary to the care plan's directive to cut food into bite-sized pieces. R55, diagnosed with Alzheimer's disease and other conditions, is dependent on staff for eating and requires a mechanically altered diet. During the observation, RTL-E did not use the appropriate clothing protector as specified in R55's care plan. Instead, a cloth napkin was used, and RTL-E continued to stand while feeding R55, which is against the facility's policy. The surveyor noted that the residents were not required to be six feet apart, contradicting RTL-E's justification for standing. These actions demonstrate a failure to adhere to the residents' care plans and the facility's policies, resulting in a deficiency in maintaining the residents' dignity during meals.
Failure to Monitor Resident's Weight Consistently
Penalty
Summary
The facility failed to provide adequate nutritional support to a resident, identified as R72, by not consistently monitoring their weight as per physician's orders. R72, who was admitted with diagnoses including cognitive communication deficit, congestive heart failure, and intracerebral hemorrhage, had a physician's order to have their weight monitored twice weekly. However, there were multiple instances of missing weight documentation on scheduled bath dates, which were the designated times for weight checks. This inconsistency in monitoring led to a significant weight loss of 7.6 pounds over a 10-day period, which was not reported to the physician until four days after the weight loss was noted. The surveyor's investigation revealed that the facility's CNAs were responsible for obtaining weights and reporting them to the unit nurse for documentation. The dietician confirmed that significant weight changes, such as the 7.6-pound loss, should be reported to the physician. During an interview, the Nursing Home Administrator acknowledged that R72 occasionally refused care, but a comprehensive care plan addressing these refusals was only implemented on the day of the surveyor's exit meeting. The delay in notifying the physician of the weight loss and the lack of consistent weight monitoring contributed to the deficiency identified by the surveyor.
Improper Disinfection of Glucometer
Penalty
Summary
The facility failed to ensure proper cleaning and disinfecting of a resident's glucometer after each use, as observed by a surveyor. During a medication administration task, an LPN was seen using a glucometer to check a resident's blood glucose level without cleaning it afterward. The LPN placed the glucometer directly on the medication cart and then back into a plastic bag without using a disinfectant wipe that kills blood-borne pathogens. The LPN mentioned that the night shift nurses were responsible for cleaning the glucometers daily, using alcohol prep wipes containing 70% isopropyl alcohol, which are not effective against blood-borne pathogens. Interviews with facility staff, including a CMA and the DON, revealed inconsistencies in the facility's procedures for disinfecting glucometers. The CMA described a process involving alcohol prep wipes, while the DON mentioned using alcohol-based wipes or purple top sani-wipes after each use. The surveyor noted the absence of disinfectant bleach wipes on the medication cart and expressed concern about the use of alcohol-based wipes, which are inadequate for disinfecting against blood-borne pathogens. The facility did not provide additional information to address these concerns.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Elkhorn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holton Manor | 0.4 mi | ★★★★★ | 19 | 0 |
| Delavan Health Services | 6.1 mi | ★★★★★ | 0 | 0 |
| Williams Bay Health Services | 7.1 mi | ★★★★★ | 36 | 1 |
| Geneva Lake Manor | 8.7 mi | ★★★★★ | 9 | 1 |
| East Troy Manor | 9.6 mi | ★★★★★ | 5 | 0 |
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