Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lindengrove Waukesha during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide required written bed-hold information and to notify the State LTC Ombudsman for multiple facility-initiated discharges to the hospital. In three separate unplanned transfers, residents were sent to an acute hospital and did not return, yet there was no documentation that the bed-hold policy, daily cost, or appeal rights were explained, and no completed bed-hold forms were found in the EMR. The SSD and nursing leadership confirmed that bed-hold documentation was missing, and the Ombudsman reported not receiving the facility’s discharge notifications, despite facility policy requiring that residents or their representatives receive written bed-hold information at transfer and that all facility-initiated discharges, including hospitalizations, be reported to the Ombudsman.
A resident with severe cognitive impairment, dementia, Alzheimer’s disease, unsteadiness, and psychotropic medication use had repeated falls, including one that caused blunt head trauma, a forehead laceration, and an intracranial hemorrhage. The facility’s fall investigations were often incomplete or inconsistent, with missing documentation on toileting, footwear, call light status, and prior interventions, and the stated root causes changed or were vague. Fall care plan interventions were often added days later and were not always in place or documented, and the resident’s behavior and psychotropic-drug care plans were not active despite CAA findings tied to fall risk.
Missing transfer and bed-hold notices for hospitalized residents: The facility did not provide required written transfer/discharge notices, appeal rights, Ombudsman contact information, bed-hold policy information, or bed-hold rates for multiple residents sent to the hospital. Records for several residents showed hospital transfers for changes in condition, but no corresponding notices were found, and staff gave conflicting statements about who was responsible for completing the forms.
A facility failed to ensure that a CNA completed the required effective communication program training. Record review showed no documentation of the training, and the LF confirmed the CNA had not yet completed it. The NHA later acknowledged the mandatory training had not been provided.
A CNA did not have documentation showing completion of the facility’s required QAPI training. The surveyor reviewed the CNA’s training record, found the QAPI training missing, and the LF confirmed the training had not yet been completed. The NHA later acknowledged the CNA had not received the mandatory QAPI training.
A CNA did not have documentation of completing the facility’s required compliance and ethics program training. The surveyor reviewed the CNA’s training record, confirmed with the LF that the training had not yet been completed, and the NHA later acknowledged the mandatory training had not been provided.
Two residents experienced failures in timely and complete reporting of alleged abuse and misappropriation. In one case, a resident's missing wallet was initially reported and investigated, but the required 5-day follow-up report was not submitted to the State Agency. In another case, a resident reported being yelled at and scared by a CNA, but the incident was not reported or documented as required, and management was unaware until informed by a surveyor. Both incidents reflect noncompliance with the facility's policy for reporting abuse and misappropriation.
Failure to Obtain Guardian Consent for Psychoactive Medications: A resident with dementia and Major Depressive Disorder, who had an activated guardian, received Seroquel and Zoloft without prior consent from the guardian. Record review showed the psychoactive meds were administered before signed consent was obtained, and the DON stated consent is required before administration but did not know why it was not obtained earlier.
Missing Behavior and Psychotropic Care Plans: The facility failed to develop comprehensive person-centered care plans for 2 residents with dementia-related behaviors and psychotropic medication use. One resident had rejection of care, pacing, and aggression, while the other had severe cognitive impairment, verbal outbursts, and antipsychotic use; neither care plan included the documented behaviors or non-pharmacological interventions, and one resident also lacked an active psychotropic drug use plan despite CAA findings.
Failure to Complete Neuro Checks After Unwitnessed Falls: The facility did not document neuro checks after unwitnessed falls for two residents. One resident with dementia, severe cognitive impairment, and high fall risk had multiple unwitnessed falls, including events with pain and head injury, but no completed neuro checks were found in the record. Another resident with Alzheimer’s disease, severe cognitive impairment, and a history of falls also had unwitnessed falls, including one with a bleeding head injury and hospital transfer, but survey review did not locate the required neuro check documentation.
A resident with DM1, CKD, chronic respiratory failure, and other comorbidities admitted with a right heel pressure injury, but the facility only documented pressure to the heel without a full wound description, measurements, or staging. The wound was not comprehensively assessed until the wound MD saw it several days later and documented an unstageable DTI with moderate serosanguinous exudate. The record also showed the ordered wound treatment was not implemented as written at first, and surveyor review found no evidence of a timely comprehensive assessment after admission.
The facility did not follow up on repeated pharmacist monthly medication regimen review recommendations for residents receiving antipsychotic medications. A resident with bipolar disorder and dementia, and two other residents with dementia-related diagnoses, had pharmacy reviews that repeatedly called for AIMS or tardive dyskinesia assessments, but the assessments were not completed as recommended and the DON acknowledged the missed follow-up.
Medication administration errors caused the facility’s medication error rate to exceed the allowed threshold. An LPN and a nurse extern were observed crushing or opening medications that were delayed release or enteric coated, including Divalproex, Pregabalin, and Ferrous Sulfate EC, and administering them with food. In addition, a resident’s Apixaban doses were documented as held even though the medication was available in contingency supply, and there was no progress note documentation or physician notification.
A resident on hospice with advanced dementia and a history of falls had hospice PRN meds ordered, but the facility delayed entering the Lorazepam and Hydromorphone orders into the chart and did not notify hospice of multiple falls on the day they occurred. Staff also could not locate the resident’s hospice binder at the nurse’s station, despite using it as a communication tool between hospice and facility teams.
A resident with diabetes and a recent hospital stay did not receive prednisone according to the prescribed tapering schedule due to transcription errors in the EMR, resulting in missed and incorrect doses. Additionally, staff failed to notify the provider of two blood glucose readings over 400 mg/dL, with no documentation of provider notification or additional interventions, despite facility policy requiring such actions.
Two residents with newly identified or existing pressure injuries did not receive timely wound treatment orders. In both cases, wounds were identified and noted in documentation, but treatment orders were either not entered into the EMR or were delayed for an extended period. Facility policy required prompt assessment and provider notification, but these steps were not consistently followed, resulting in a lack of timely wound care.
Two residents with chronic respiratory conditions did not receive their prescribed inhalers as ordered due to medication unavailability. Staff documented missed doses and contacted the pharmacy, but there were delays in obtaining necessary management authorization for high-cost medications and breakdowns in communication, resulting in multiple missed doses despite pharmacy attempts to supply the medications.
A resident at high risk for pressure injuries developed new wounds due to the facility's failure to implement necessary interventions, such as an air mattress and repositioning. The care plan was not updated with recommended interventions, and weekly skin assessments were not completed. Observations showed non-compliance with orders for offloading and repositioning, leading to the deterioration of the resident's condition.
The facility failed to maintain proper sanitation and food handling practices, with soiled garbage cans, undated and uncovered food items, and improperly stored scoops in the kitchen. Additionally, a dirty mop and bucket were found near a food service cart in a serving area, and sinks were observed to be very dirty. These issues were noted to potentially affect 44 residents.
The facility did not provide adequate telephone access for residents on the second floor, affecting their privacy during calls. While first-floor residents had phones in their rooms, those on the second floor had limited access, with only two cordless phones available, one of which was inoperable. A nurse often used her personal phone to facilitate private calls for residents, as the facility's landline was located in the nurse's station, which did not allow for privacy.
A resident was observed self-administering medications without a proper assessment or physician's order, contrary to facility policy. The resident's medical record lacked documentation of an assessment or care plan for self-administration, and an LPN marked the medications as administered on the MAR. The facility acknowledged the oversight and conducted the necessary assessment and review the following day.
A resident with severe cognitive impairment fell and was hospitalized with a hip fracture and brain bleed. The facility failed to notify the resident's representative and attending physician of the incident, as confirmed by the surveyor's review and the Interim DON. The agency nurse involved could not recall making the necessary notifications.
A resident with severe cognitive impairment was prescribed Trazodone and Mirtazapine without obtaining informed consent from their POA, as required by the facility's policy. The oversight was acknowledged by the DON during a survey, highlighting a failure to comply with the protocol for informed consent for psychoactive medications.
A resident reported two shirts missing after being laundered by the facility. Despite notifying staff and discussing the issue in a resident council meeting, the facility did not follow up adequately. Interviews revealed unclear protocols for handling missing items, and no grievance was filed. The facility lacked a policy on missing items, leading to unresolved issues.
A resident admitted with chronic conditions did not receive a baseline care plan review or a copy within 48 hours, as required by facility policy. Despite being cognitively intact, the resident was not involved in the care planning process, and the signed care plan was missing from the medical record. Interviews with nursing directors confirmed the policy was not followed.
A resident at risk for pressure injuries did not have a comprehensive care plan in place, despite being identified as at risk through assessments. The resident was observed using preventive measures like a pressure reduction mattress, but the facility's policy requiring a documented care plan was not followed. The deficiency was acknowledged by the DON, but no corrective actions were provided during the survey.
Two residents in an LTC facility, both with severe cognitive impairments and dependent on staff for ADLs, were found with long, dirty fingernails. One resident was observed scratching open wounds, while the other had contracted fingers with nails touching the palms. Despite facility policy requiring nail care on bath days, there was no documentation or consistent performance of this care. Staff were unsure about the inclusion of nail care in care plans, and the deficiency was reported to the interim DON and NHA.
The facility failed to provide meaningful weekend activities for two residents, who expressed a desire for organized group activities. Instead, the facility offered activity packets and TV options, which did not meet the residents' needs. Additionally, the facility did not complete a required section of the MDS for one resident, documenting their activity preferences.
A resident admitted to a facility after a fall with head trauma was assessed as high risk for falls, but a falls care plan was not initiated until nearly two months later. The resident experienced multiple falls during this period, and the care plan was not updated following these incidents. Despite reminders to use the call light, the resident continued to self-transfer, leading to further falls. Staff interviews indicated the resident preferred independence but was compliant with call light use in recent months. The facility's failure to implement timely and effective fall prevention measures demonstrated a deficiency in care.
A resident with an indwelling catheter lacked a valid medical justification, monitoring, and care plan, leading to deficiencies in catheter care and dignity. The resident, with multiple diagnoses and on hospice care, had no documented orders or interventions for catheter management. Observations showed the catheter bag was not in a privacy bag, and staff were unsure about care procedures, highlighting a failure to follow facility policy.
A resident with chronic respiratory issues and on hospice care was found to have unlabeled oxygen tubing and no protective coverings as per facility protocol. There was no care plan for oxygen use, and staff were unclear about procedures for replacing and labeling oxygen equipment, leading to inconsistent care.
The facility failed to ensure accurate medication administration for two residents. A resident did not receive Hydrochlorothiazide as it was not found in the cart, yet it was signed as given. Another resident did not receive Voltaren gel because it was used up and not reordered, but it was also signed as administered. Both medications were available in the Omnicell system, indicating a failure in following procedures.
Two residents in a LTC facility were not adequately monitored for the effectiveness and side effects of their psychotropic medications. One resident was prescribed Duloxetine for depression without a care plan or monitoring, despite having no depressive symptoms. Another resident was on Trazodone and Mirtazapine without behavior monitoring to assess medication effectiveness. Staff were unaware of specific monitoring requirements, and the facility's psychoactive medication protocol was not followed, leading to deficiencies in medication management.
The facility experienced a medication error rate of 11.11%, exceeding the acceptable 5% threshold. Three residents were affected: one did not receive Voltaren Gel, another missed a dose of Hydrochlorothiazide, and a third did not receive Amlodipine, despite all being signed out as administered. Medications were available in the Omnicell system but were not given, and documentation errors were noted.
A resident received double the prescribed dose of Vancomycin due to a transcription error, resulting in 16 extra doses being administered over a period. The error was identified by a surveyor, and no negative effects were found in the resident's medical record.
The facility failed to properly store and label medications, with deficiencies noted in 3 out of 5 medication carts/storage rooms. Temperature logs were missing or incomplete in medication storage rooms, and insulin glargine was stored beyond its use-by date. The Interim DON confirmed the lack of temperature monitoring, and the surveyor noted the expired insulin was still in use despite guidelines.
The facility did not post daily nurse staffing data, including the date, resident census, and total hours worked by RNs, LPNs, and CNAs. A surveyor found outdated postings, and interviews revealed confusion about who was responsible for updates on weekends or when the scheduler was absent. This affected all 44 residents.
A facility failed to accurately document a resident's code status in the EMR, showing the resident as a Full Code despite having a DNR order. This discrepancy was discovered when the resident was found nonresponsive, and the family had to sign another DNR form.
A facility failed to properly assess and monitor a resident, resulting in the development of a stage 3 pressure injury. Despite being at risk, the resident's care plans lacked preventive interventions, and required skin checks were not documented. Staff interviews revealed a lack of awareness of the injury, and the facility could not provide additional information on its development.
A resident with Alzheimer's Disease and severe cognitive impairment experienced an unwitnessed fall, which was not documented or investigated by the facility. Despite multiple attempts to contact the nurse on duty, no additional information was obtained, violating the facility's policy for fall incident review.
A resident with moderate cognitive impairment and frequent incontinence was left in wet clothing for an extended period, from at least 12:40 PM to 2:10 PM, without being checked or changed. The CNA responsible admitted to not checking the resident since 10:00-10:30 AM, citing understaffing. This neglect was confirmed by the ADON, who acknowledged that residents should be checked every two hours.
A CNA failed to change gloves during incontinence care for a resident with right hemiplegia, Alzheimer's disease, and dementia. The CNA used the same gloves to clean the resident's perineal area, apply a clean brief, and change the resident's oxygen tubing, violating the facility's hand hygiene policy.
Failure to Provide Bed-Hold Notices and Notify Ombudsman of Facility-Initiated Discharges
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notification of its bed-hold policy to residents and/or their representatives prior to transfer to the hospital, and failure to notify the State Long-Term Care Ombudsman of facility-initiated discharges. For one resident (R1), who had moderately impaired cognition with a BIMS score of 11/15, the EMR showed an unplanned transfer to an acute hospital after staff noted a cut, bruise, and bleeding on the right eyelid and sent the resident for evaluation. Progress notes documented that the POA was notified of the transfer and later contacted about whether the bed should be held, with the POA declining. However, there was no documentation that the bed-hold process, including cost per day and appeal rights, was explained, no completed bed-hold form, and no documentation that the Ombudsman was notified of the facility-initiated discharge. For a second resident (R9), who had no cognitive impairment with a BIMS score of 15/15, the admission and discharge-return-anticipated MDS assessments showed an unplanned discharge to an acute hospital from which the resident did not return. Review of the EMR revealed no documentation that a bed hold was discussed with the resident or representative at the time of transfer, no record of the daily cost of services, and no indication of whether a bed hold was chosen. There was also no documentation that the Ombudsman was notified of this facility-initiated discharge to the hospital. During interview, the Social Services Director confirmed that a bed-hold form was not completed for this resident. For a third resident (R10), the records showed an unplanned discharge to the hospital for abnormal vital signs, with no return to the facility. EMR review again showed no documentation that a bed hold was discussed with the resident or representative, no record of the cost per day, and no indication of a decision regarding bed hold. There was also no documentation that the Ombudsman was notified of this discharge. The Social Services Director described a practice of faxing a monthly admissions/discharge report to the Ombudsman and then discarding the fax documentation, and the Ombudsman’s office reported not having received the facility’s monthly discharge lists since a specified prior date and stated the facility was told to maintain documentation of these notifications. Facility policies required that residents/representatives be informed and receive a copy of the bed-hold procedure upon transfer, that responses be documented, and that the appropriate Ombudsman be notified of all facility-initiated discharges, including hospitalizations, but these requirements were not met for the three reviewed residents.
Inadequate supervision and incomplete fall investigations
Penalty
Summary
The facility did not ensure adequate supervision and fall-prevention interventions for residents with a history of falls, including a resident with severe cognitive impairment, dementia, Alzheimer’s disease, unsteadiness on feet, muscle weakness, and psychotropic medication use. The report states that this resident experienced multiple falls after admission, including an initial fall on 7/18/25 that resulted in blunt head trauma, a forehead laceration requiring sutures, and traumatic intracranial hemorrhage. After returning from the hospital, the resident continued to fall repeatedly at the facility, with several falls occurring in the common areas, dining room, room, and while in a wheelchair. The facility’s fall investigations were repeatedly incomplete or inconsistent. For multiple falls, staff did not document when the resident was last toileted or checked, what footwear the resident was wearing, whether call light access was available, or whether prior interventions were in place at the time of the fall. The investigations often listed vague or changing root causes, such as restlessness, trying to stand, trying to ambulate without assistance, or being brought to the dining room early, but the report states these explanations were not supported by documentation. Staff statements were generally not collected beyond the nurse’s note, and surveyors noted discrepancies between staff recollections and the DON’s explanations. The resident’s fall care plan interventions were not consistently implemented or documented in a timely manner. Several interventions were added days after the falls, and surveyors observed that some fall-related interventions were not in place during the survey process. The resident’s care plan included supervision at the nurse’s station, tray tables, activities to keep the resident busy, and later a Broda chair, but the report states these interventions were not always present when needed. The facility also failed to maintain active care plans for the resident’s behaviors and psychotropic drug use despite CAA findings that the resident’s dementia, behaviors, and medications increased fall risk. The report identifies the facility’s failure to provide adequate supervision, thoroughly investigate falls, and implement resident-centered interventions as the basis for the deficiency, and states that the failure related to the resident’s repeated falls and injuries.
Missing transfer and bed-hold notices for hospitalized residents
Penalty
Summary
The facility did not ensure that written transfer/discharge notices and bed-hold information were provided to residents and/or their representatives when residents were sent to the hospital. The report identified 6 residents reviewed for hospitalizations—R3, R4, R1, R8, R19, and R47—who did not have documentation showing they received the required notice of transfer, reason for transfer, location of transfer, appeal rights, and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman, along with written notice of the reason for transfer/discharge, bed-hold policy, and the rate to reserve the bed. R3 was transferred to the hospital twice, and no written transfer notice or bed-hold rate was found in the record for either hospitalization. R4 was also transferred to the hospital twice, and no transfer notice or bed-hold rate was located for either event. R1, who had diagnoses including bipolar disorder, dementia, and paraplegia, was transferred to the hospital for a change in condition, but there was no documentation that a written transfer notice or bed-hold rate was provided. R8, who had diagnoses including right femur fracture, difficulty walking, and weakness, was transferred to the hospital twice for a change in condition, and no written transfer notice or bed-hold rate was documented for either transfer. R19 was transferred to the hospital, and no bed-hold or transfer notice could be located in the medical record. R47, who had diagnoses including hepatic encephalopathy, metabolic encephalopathy, infection and inflammatory reaction due to an indwelling urethral catheter, severe protein-calorie malnutrition, alcohol dependence with alcohol-induced persisting dementia, urinary retention, second-degree AV block, and anemia, was hospitalized for a change in condition, but there was no evidence that a written transfer notice or bed-hold rate was provided. During interviews, the DON stated there were no bed-hold or transfer notices completed for several of the residents, and staff gave conflicting responses about who was responsible for completing the notices.
Missing Required Effective Communication Training for CNA
Penalty
Summary
The facility did not ensure that all staff received the required effective communication program training for 1 of 5 sampled CNAs, CNA-W. Record review on 09/25/24 showed no documentation that CNA-W had completed training on the facility’s effective communication program, which was intended to outline and inform staff of the elements and goals of the program. When the missing documentation was requested from the NHA, the surveyor was directed to the Learning Facilitator, who tracked staff education. During a phone interview, the Learning Facilitator stated that CNA-W had not yet completed the required training. The NHA later confirmed that the facility had not provided CNA-W with the mandatory training and stated the facility was working on providing it.
Missing Mandatory QAPI Training for CNA
Penalty
Summary
The facility did not ensure that all staff received the required Quality Assessment and Performance Improvement (QAPI) program training for one of five sampled CNAs, CNA-W. On 09/25/24, the surveyor reviewed CNA-W’s completed trainings for the past year and found no documentation showing completion of the facility’s QAPI training, which was intended to outline and inform staff of the elements and goals of the QAPI program. When the surveyor requested the missing documentation from the NHA, the NHA directed the surveyor to the Learning Facilitator, who tracked staff education. During a phone interview, the Learning Facilitator stated that CNA-W had not yet completed the required QAPI training. The NHA later confirmed that the facility had not provided CNA-W with the mandatory QAPI training and stated the facility was working on providing it.
Missing Compliance and Ethics Training for CNA
Penalty
Summary
The facility did not ensure that all staff received the required compliance and ethics program training for 1 of 5 sampled CNAs, identified as CNA-W. On 09/25/24, the surveyor reviewed CNA-W’s completed trainings for the past year and found no documentation showing completion of the facility’s compliance and ethics program training. When the surveyor requested the missing documentation from the NHA, the NHA directed the surveyor to the Learning Facilitator, who tracked staff education. During a phone interview, the Learning Facilitator stated that CNA-W had not yet completed the required compliance and ethics program training. The NHA later confirmed that the facility had not provided CNA-W with the mandatory training and stated the facility was working on providing it, but no additional reason was given for why the training had not been completed.
Failure to Timely Report Alleged Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure timely and complete reporting of alleged abuse and misappropriation involving two residents. In the first case, a resident with severe cognitive impairment and multiple medical conditions, including dementia and a recent fall with fracture, was reported by their Activated Power of Attorney (APOA) to have a missing wallet. The Director of Nursing (DON) was notified, and an initial report was submitted to the State Agency on the same day. The facility initiated an investigation and contacted local law enforcement. However, the required 5-day follow-up report to the State Agency was not submitted. The Nursing Home Administrator (NHA) acknowledged the omission, citing issues with email account changes and inability to locate confirmation of the 5-day report submission. In the second case, a cognitively intact resident reported to a surveyor that a Certified Nursing Assistant (CNA) had yelled at and scared them several weeks prior. The resident had informed another CNA, who stated they would file a complaint but did not do so, nor did they inform facility management. The incident was not documented in the facility's incident or grievance logs for the relevant period. When interviewed, the CNA who received the complaint did not consider the situation abusive and did not escalate the report. Facility management, including the Assistant Director of Nursing (ADON) and Social Worker (SW), were unaware of the incident until informed by the surveyor. A grievance was only filed after the surveyor's inquiry, and the alleged perpetrator was no longer employed at the facility. The facility's own policy requires immediate or timely reporting of all allegations of abuse, neglect, or misappropriation to the State Agency and other authorities, as well as submission of a follow-up investigation report within five working days. In both cases, the facility failed to adhere to these requirements: the 5-day follow-up report was not submitted for the missing wallet, and the verbal abuse allegation was not reported to the State Agency at all. These failures were confirmed through interviews and record reviews conducted by the surveyor.
Failure to Obtain Guardian Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that a resident with dementia and Major Depressive Disorder, who had an activated Power of Attorney/Guardian, was fully informed and had consent obtained before psychoactive medications were administered. Record review showed the resident received Quetiapine Fumarate (Seroquel) 25 mg at bedtime and Sertraline 50 mg in the morning, both ordered for ongoing use, while the resident’s medical record did not show consent from the guardian before administration began. The resident’s quarterly MDS documented daily use of antipsychotic and antidepressant medications during the assessment reference period. The medical record contained signed consent from the guardian dated later than the medication start dates, and the consent referenced anticipated dosage ranges for Quetiapine and Sertraline. During interview, the DON stated that consent is needed from either the resident or the guardian before psychoactive medication is administered, and stated she did not know why consent was not obtained before the resident received Sertraline or Quetiapine.
Missing Behavior and Psychotropic Care Plans
Penalty
Summary
The facility did not develop and implement comprehensive person-centered care plans for 2 residents with documented behavioral and psychotropic medication needs. R2 was admitted with diagnoses including anxiety and dementia with behavioral disturbance, and her quarterly MDS documented rejection of care 1-3 days during the reference period. Her current orders included Seroquel 25 mg twice daily for dementia with behavioral disturbance, but her care plan only addressed monitoring for psychotropic side effects and did not include non-pharmacological interventions for pacing, violence, aggression toward staff and others, or the rejection of care noted on the MDS. R13 was admitted with diagnoses including Alzheimer's disease with late onset, dementia with agitation, and depression, and her admission MDS documented severe cognitive impairment and verbal behaviors toward others 4-6 days per week. Her CAA documented yelling out/screaming, a new environment contributing to increased behaviors and confusion, and a plan of care for improvement in behaviors; the psychotropic drug use CAA also documented anti-depressant and anti-psychotic use, medication refusals, and three falls since admission. Despite these assessments and a physician order for Seroquel 25 mg three times daily, the comprehensive care plan did not include an active behavior care plan or an active psychotropic drug use care plan addressing her behaviors or non-pharmacological interventions.
Failure to Complete Neuro Checks After Unwitnessed Falls
Penalty
Summary
The facility did not complete neurological checks in accordance with facility protocol and standards of practice after unwitnessed falls for 2 residents, R2 and R13. The facility did not have a neurological check policy, although an undated facility document titled "Neurological Flow Sheet" described a schedule for vital signs and neuro checks at the time of the event, every 30 minutes x 2, every 1 hour x 4, and every shift x 3, progressing only if signs were stable. The American Association of Post-Acute Care Nursing document cited in the report stated that a neuro check should be done when a resident hits his or her head or if it is unknown whether the resident hit the head during an unwitnessed fall. R2 had diagnoses including dementia with behavioral disturbance, generalized anxiety disorder, and depression, and was documented as severely cognitively impaired, wheelchair dependent, and at high risk for falls. R2 sustained multiple unwitnessed falls on 1/31/25, 2/2/25, 2/3/25, 5/16/25, and 7/1/25. For each of these falls, the record showed staff assessments and, in some instances, transfer to the hospital, but survey review did not locate completed neuro checks in the paper documentation or electronic medical record. One fall note documented that R2 complained of all over pain after being found on the floor; another documented that R2 reported hitting the head and had a lump developing on the back of the head, and the hospital record for that event listed a closed head injury. The facility fall investigation for the 7/1/25 event also identified the fall as unwitnessed, but no completed neuro checks were found. R13 had diagnoses including Alzheimer’s disease with late onset, dementia with agitation, depression, muscle weakness, and unsteadiness on feet, and was documented as severely cognitively impaired with a history of falls and high fall risk. R13 sustained unwitnessed falls on 9/2/25 and 9/7/25. The 9/2/25 progress note stated that neuro checks were negative, but survey review did not locate completed neuro check documentation in the paper record or electronic medical record. For the 9/7/25 fall, staff documented that R13 had a bleeding head injury and was sent to the hospital; the emergency department note described an unwitnessed fall with a bleeding hematoma on the left forehead and abrasions. Survey review did not find a fall investigation or neuro check documentation for that event, and the record showed R13 returned to the facility the same day.
Incomplete Admission Assessment of Pressure Injury
Penalty
Summary
A resident admitted with a right heel pressure injury and multiple chronic conditions, including diabetes mellitus type 1, kidney transplant status, chronic kidney disease, chronic respiratory failure with hypoxia, encephalopathy, atrial fibrillation, dysphagia, hypothyroidism, hyperlipidemia, and atherosclerotic heart disease. On admission, the facility documented only that there was pressure to the right heel, but there was no comprehensive assessment describing the wound, measuring it, or staging it. The resident’s Braden score was 16, indicating risk for pressure injury development, and the care plan identified an actual deep tissue injury to the right heel with pressure-relieving boots while in bed or chair. The resident’s admit/readmit screener also listed the right heel pressure injury without documentation of length, width, depth, or stage. The only early documentation located was a progress note describing a right heel scabbed area that was cleansed and rebandaged for protection. The facility’s skin and wound evaluation later documented a deep tissue injury of the right heel present on admission, but still did not include measurements or wound bed description. The wound physician’s initial evaluation, completed 6 days after admission, documented the wound as an unstageable DTI within and around the wound with moderate serosanguinous exudate and measured the wound at 1 x 0.6 x 0.1 cm. The physician ordered Leptospermum honey and a foam border dressing three times per week and as needed, but the resident’s August TAR documented a different treatment of cleansing and border foam dressing, and the ordered honey was not implemented until later. The physician later documented the wound as improved with decreased surface area. Surveyor review and interviews with the DON and MD showed the facility relied on the admission skin check and weekly wound rounds, but there was no evidence of a comprehensive wound assessment upon admission or the next day, despite the resident’s pressure injury being present on admission and later documented as open with exudate.
Failure to Follow Monthly Pharmacist Review Recommendations for AIMS Assessments
Penalty
Summary
The facility did not ensure that a licensed pharmacist’s monthly drug regimen reviews were followed up on for residents receiving antipsychotic medications, and irregularities identified in those reviews were not addressed as documented in the facility’s policy. The consultant pharmacist’s reports stated that recommendations were to be acted upon and documented by facility staff and/or the prescriber, but the record showed repeated recommendations for Abnormal Involuntary Movement Scale (AIMS) or tardive dyskinesia assessments that were not completed for multiple residents. For one resident with bipolar disorder, dementia, and paraplegia, the medical record showed prescriptions for aripiprazole and lamotrigine, along with prior AIMS assessments in 2024. The pharmacist’s monthly reviews on multiple occasions in 2025 recommended that an AIMS assessment be completed because the resident was receiving antipsychotic medication, but the facility did not follow up on those recommendations. The DON acknowledged that the resident did not have the recommended AIMS assessments completed and stated the facility had not followed up on the pharmacist’s recommendations. For two other residents, the pharmacist’s monthly reviews also repeatedly recommended AIMS screening because of Seroquel or quetiapine use. One resident had diagnoses including anxiety and dementia with behavioral disturbance and was receiving Seroquel twice daily; pharmacy reviews over several months recommended an AIMS assessment, but no AIMS was found in the record. Another resident with dementia and major depressive disorder was receiving quetiapine for dementia with mood disturbance; the pharmacist recommended an AIMS assessment on more than one review, but the facility did not act on the recommendation until after a later review questioned why it had not been completed. The DON confirmed that the assessment had not been completed per policy and that it was completed only after the pharmacist’s repeated recommendation.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility did not ensure its medication error rate remained below 5 percent; the reported medication error rate was 11.54%. During observation, interview, and record review, a nurse extern prepared and administered R24’s medications by crushing tablets and opening capsules into applesauce. The medications included Divalproex delayed release capsules and Pregabalin capsules, along with several tablets. The Divalproex delayed release capsules were opened and emptied into the applesauce, and the Pregabalin capsule was also opened and emptied into the same mixture, despite the facility policy stating that long-acting or enteric-coated dosage forms should not be crushed and alternatives should be sought. For R24, the MAR documented Apixaban 5 mg ordered twice daily, but the nurse extern entered the AM dose as held on 9/9/25 and again on 9/10/25, stating the medication was not available and that pharmacy would need to be called. The nurse extern later stated Apixaban was available in contingency supply, and the surveyor verified Apixaban 2.5 mg tablets were available in the Omnicell contingency supply. There was no documentation in progress notes regarding holding the medication or physician notification. For R47, an LPN prepared medications that included Ferrous Sulfate EC 325 mg, then crushed all the tablets together and administered them in pudding, even though the MAR documented Ferrous Sulfate as an enteric-coated delayed release tablet.
Hospice communication and medication orders not timely implemented
Penalty
Summary
The facility failed to ensure hospice collaboration and communication were established to maintain continuity of care for a resident receiving hospice services. The resident had diagnoses including Alzheimer's disease with late onset, dementia with agitation, depression, muscle weakness, and unsteadiness on feet, and the MDS described the resident as severely cognitively impaired, verbally behaviorally directed toward others several days a week, dependent for toileting and hygiene, and with a history of falls. Hospice services began with a plan of care that included Lorazepam for anxiety and Hydromorphone for pain or shortness of breath, but the facility did not enter the hospice medication orders into the resident's chart when hospice started. The hospice medication orders were not entered until much later, with Lorazepam entered after the order had been in place for weeks and Hydromorphone entered even later after surveyor inquiry. Facility leadership stated staff were concerned Lorazepam could increase fall risk and be considered a chemical restraint, and also stated the hospice medication orders had been missed. Hospice notes showed staff discussed using Lorazepam, but the facility had not implemented the order in the resident's record for an extended period. The resident also had multiple falls during the hospice period, including falls documented on several dates, and facility staff did not inform hospice of those falls on the day they occurred. The report also documented that the resident was supposed to have a hospice binder at the nurse's station to support communication between hospice and facility staff, but surveyors could not locate the binder at the nurse's station on multiple observations. Hospice staff and facility staff both referenced the binder as part of their communication process, yet the binder was not available for surveyor review and was not observed where staff said it should be. Hospice staff confirmed they were not made aware of the resident's falls on several occasions, and the facility's documentation did not show timely hospice notification for those events.
Failure to Accurately Transcribe Medication Orders and Notify Provider of Elevated Blood Glucose
Penalty
Summary
The facility failed to accurately transcribe and administer a prednisone taper as ordered for a resident who was readmitted following a hospital stay. The hospital discharge summary specified a tapering schedule for prednisone, but the orders entered into the electronic medical record (EMR) did not match the hospital's instructions. The medication administration record (MAR) showed inconsistencies in the dosage and administration dates, with some doses marked as refused and others not aligning with the prescribed taper. The resident reported receiving incorrect doses and missing doses on certain days. Additionally, the facility did not notify the provider of elevated blood glucose levels for the same resident, who had a diagnosis of diabetes mellitus. The resident's care plan included blood sugar monitoring as ordered by the physician, but the initial orders lacked specific parameters for when to notify the provider. Blood glucose readings over 400 mg/dL were recorded on two occasions, but there was no documentation that the provider was notified or that additional insulin or rechecks were performed. Staff interviews revealed uncertainty about notification protocols in the absence of explicit parameters, and the Director of Nursing confirmed that there was no evidence of provider notification for the elevated readings. The resident was cognitively intact and able to report her experiences, stating that staff did not respond to her high blood glucose readings and that she did not receive the correct prednisone taper. The facility's policies required medications to be administered as prescribed and for providers to be updated as needed, but these protocols were not followed in this case, resulting in the deficiencies identified.
Failure to Obtain Timely Wound Treatment Orders for Pressure Injuries
Penalty
Summary
The facility failed to obtain timely wound treatment orders when pressure injuries were identified for two residents. For one resident admitted with surgical aftercare and muscle weakness, a new mixed stage 1-2 pressure injury was identified during care, and although the medical doctor was notified and orders were reportedly received, no treatment orders were entered into the electronic medical record (EMR) during the resident's stay. The care plan did not address the pressure injury until several days later, and the wound was not entered into the facility's risk management system. Interviews with nursing staff and administration confirmed that the expected process of documenting the wound, obtaining and entering orders, and updating the care plan was not followed. Another resident, admitted with diabetes and vascular dementia, had a stage three pressure injury to the coccyx upon admission. Documentation showed that no treatment order for this wound was entered until two weeks after admission, despite the presence of the wound being noted in nursing assessments. The only order present on admission was for a moisture barrier cream, which was not signed off as administered. The facility's wound nurse confirmed that there was no wound nurse or system in place prior to her tenure, and that treatment orders were not obtained in a timely manner for this resident's pressure injury. Facility policy required collaboration with the interdisciplinary team, prompt skin assessments, provider notification, and timely updates to care plans and treatment orders for any abnormal skin findings. However, in both cases, the process for obtaining and documenting wound care orders was not followed, resulting in a lack of timely treatment for identified pressure injuries.
Failure to Provide Ordered Respiratory Medications Due to Availability Issues
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered as ordered for two residents with chronic respiratory conditions. For one resident with chronic respiratory failure and hypoxia, there was an order for a Breztri inhaler to be given twice daily. Documentation showed that multiple doses were not administered because the medication was unavailable, with staff indicating that the pharmacy required management authorization due to the high cost. Despite pharmacy requests for authorization, the necessary approval was not completed, and the medication was not received or administered as ordered. Nursing staff documented the unavailability and contacted the pharmacy, but there was a lack of follow-up communication with management to resolve the issue, and the Director of Nursing was not aware that authorization was needed. Another resident with COPD and asthma had an order for an Advair inhaler to be administered twice daily. The medication administration records indicated several missed doses due to the inhaler being unavailable, with notes stating the pharmacy was contacted and the medication was on order. The resident reported not receiving the inhaler consistently during their stay. The pharmacy confirmed that the inhaler had been sent and should have been available for all scheduled doses, but documentation verified that not all doses were administered. The facility's policy required that if a regularly scheduled medication was not available, staff should document the reason, notify the physician if a certain number of doses were missed, and follow procedures for obtaining the medication. In both cases, there was a breakdown in communication and follow-through, resulting in residents not receiving their prescribed respiratory medications as ordered.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries and promote healing for a resident identified as high risk for pressure injuries. The resident was admitted with pressure injuries on the left heel and right lateral foot, which resolved, but later developed new pressure injuries on the right lower extremity and buttocks. Despite a physician's order for an air mattress, it was never implemented, and the care plan for actual skin impairment was not initiated in a timely manner. Weekly skin assessments were not completed as per facility policy, and the care plan was not revised with interventions to promote healing. Surveyors observed that orders for repositioning and heel offloading were not implemented, and the resident was seen removing dressings and scratching open areas with dirty fingernails. The resident's care plan and CNA Kardex were not updated with new interventions recommended by the wound care doctor, such as offloading, repositioning, and pillow boots. The facility's failure to assess and update the resident's pressure injury care plan, monitor dressings, and provide repositioning led to the development and deterioration of pressure injuries, creating a finding of immediate jeopardy. The facility's policy on pressure injury prevention and managing skin integrity was not followed, as evidenced by the lack of comprehensive assessments and documentation of the resident's pressure injuries. The resident's air mattress was not upgraded as ordered, and there were no changes to the care plan or CNA Kardex to include interventions discussed in the wound care doctor's progress notes. The facility's failure to implement changes and revisions to the care plan and CNA Kardex, complete skin assessments, and ensure interventions were in place contributed to the deficiency.
Removal Plan
- All nurses and CNAs have been educated on the facility's skin prevention policy.
- All nurses and CNAs have been educated on the notification process of skin changes. Detailing that changes be communicated to resident provider and clinical leadership who then coordinates with wound NP, dietician, and provider as needed.
- Facility skin sweep completed.
- Facility residents care plans reviewed for at risk skin and updated as needed.
- Facility residents with skin alterations have had a review of their care plan, RN comprehensive skin evaluations, interventions, and treatment plans in place.
- Daily the DON or designee will review progress notes, risk assessments and 24-hour boards for any resident alteration of skin integrity.
- Competencies and education will be conducted by nursing management and/or a nurse who has passed the competency education and has been designated to provide the education.
- Staff education will occur prior to the next shift and new agency staff will be educated upon their first shift.
- Pressure Injury Prevention and Managing Skin Integrity policy reviewed and reviewed with Medical Director.
- Interdisciplinary Team to have weekly wound meetings to review status to include: pressure injury Policy and Procedure compliance. All findings will be reported to QAPI committee.
- DON or designee will audit 5 medical records to ensure the skin policy and procedure are being followed. Findings will be reported to the QAPI committee.
- Root cause analysis completed.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, as observed in the kitchen and one of the serving areas, potentially affecting 44 residents. In the kitchen, garbage cans were found to be very soiled, and one was missing a lid near a food preparation area. Multiple food items, including a chef salad, cold cuts, fruit salad, jello, and cake, were found undated and uncovered in the refrigerator and walk-in refrigerator. Additionally, scoops were improperly stored inside bulk food bins containing flour, sugar, oatmeal, and bread crumbs, despite having designated holders. The handwashing sink in the kitchen was also noted to be very dirty. On a subsequent observation, scoops were again found improperly stored in food bins for oatmeal and food thickener. In the second-floor serving area, a mop and bucket with dirty water were placed next to a food service cart, and the sink was observed to be very dirty. The facility's policies on dining cleaning and storage were reviewed, which stated that waste receptacles should be cleaned weekly and that scoops should not be stored in food, with food items needing to be dated. These findings were communicated to the Administrator and Director of Nursing.
Inadequate Telephone Access for Second-Floor Residents
Penalty
Summary
The facility failed to ensure that residents on the second floor had reasonable access to telephones in a private setting. While residents on the first floor had telephones in their rooms, those on the second floor did not. Instead, a single phone was available at the end of the hallway, which did not provide privacy. This issue was highlighted during a Resident Council meeting where a resident expressed dissatisfaction with the lack of phones in second-floor rooms. The Nursing Home Administrator (NHA) explained that the facility had previously disconnected the phone systems on the second floor, anticipating no residents would reside there. However, residents were now living on the second floor, and the facility had not yet reinstated adequate phone access. During a surveyor's walk-through, it was observed that only two cordless telephones were available for 28 residents on the second floor, with one being inoperable. A Registered Nurse (RN) on the second floor confirmed the limited phone access and mentioned that she often used her personal cellular phone to facilitate private calls for residents, as the facility's landline was located in the nurse's station, which did not allow for privacy. The RN indicated that additional cordless telephones would be beneficial, as using her personal phone was not ideal. The surveyor informed the NHA and Director of Nursing (DON) of these findings, but no further information was provided on why the facility had not ensured adequate telephone access for second-floor residents.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure the accurate and safe administration of medication for a resident who was observed self-administering Diclofenac gel and Nystatin powder without a proper assessment or physician's order. The facility's policy requires an interdisciplinary team assessment to determine if a resident can safely self-administer medications, along with a prescriber's order. However, the resident's medical record lacked both the necessary assessment and physician's order, and there was no documentation on the care plan regarding self-administration of medication. During a medication pass observation, an LPN confirmed with the resident that they had already self-administered the medications, and subsequently marked them as administered on the Medication Administration Record (MAR). The Nursing Home Administrator later acknowledged that the assessment had not been completed, although it was intended to be done. The Acting Director of Nursing confirmed that the assessment and interdisciplinary review were conducted the following day, and a physician's order was requested. The surveyor informed the facility of these concerns during the daily exit meeting.
Failure to Notify Representative and Physician After Resident's Fall
Penalty
Summary
The facility failed to notify a resident's representative and attending physician of a change in condition following a fall with injury. The resident, identified as R45, was admitted with multiple diagnoses, including a displaced intertrochanteric fracture of the right femur and severe cognitive impairment. On the night of the incident, R45 fell and was subsequently transported to the hospital with a left hip fracture and brain bleed. Despite the severity of the incident, there was no documentation indicating that the resident's representative or attending physician was informed of the fall and subsequent hospitalization. The deficiency was identified during a surveyor's review of the electronic medical record, which revealed the absence of any notification to the family or physician after the fall. The agency nurse who attended to R45 and facilitated the hospital transfer could not recall notifying the family or physician. The Interim Director of Nursing confirmed the lack of documentation regarding the notification. The issue was brought to the facility's attention during the daily exit meeting, but no further information was provided to address the concern.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R37, was fully informed and consent was obtained for the administration of psychotropic medications. R37, who has a history of stroke, aphasia, lung cancer, and adjustment disorder with mixed anxiety and depressed mood, was prescribed Trazodone and Mirtazapine. Despite the resident's severe cognitive impairment and inability to communicate effectively, the facility did not secure written consent from R37's Power of Attorney (POA) for these medications. The facility's policy requires informed consent to be reviewed and signed by the individual or responsible party, which was not adhered to in this case. The deficiency was identified during a survey when the surveyor reviewed R37's medical records and found no documentation of informed consent for the prescribed medications. The Director of Nursing (DON) acknowledged the oversight and confirmed that consent had not been obtained. The Nursing Home Administrator was informed of the issue, but no further information was provided regarding corrective actions at the time of the survey. This oversight indicates a failure to comply with the facility's protocol for obtaining informed consent for psychoactive medications, potentially impacting the resident's right to be informed about their treatment options and associated risks.
Failure to Protect Resident's Property from Loss
Penalty
Summary
The facility failed to ensure a safe, home-like environment by not adequately protecting a resident's property from loss. A resident, who is cognitively intact with a BIMS score of 15, reported that two of her shirts went missing after being sent to the facility's laundry department. Despite the resident filling out a form with the description of the missing shirts, the facility did not follow through in a timely manner to locate the items. The resident had brought up the issue during a resident council meeting, but the facility staff assumed the issue was resolved without confirming the recovery of the shirts. Interviews with facility staff revealed a lack of clear protocol and communication regarding the handling of missing items. A CNA mentioned that they would inform a nurse and a supervisor about missing items, but was unaware of the subsequent steps if the items were not found. The Assistant Director of Nursing indicated that a grievance should be filed if items are not located, but no grievance was found in the records. The Social Worker also assumed the issue was resolved after the resident council meeting. The facility did not provide a policy on missing items when requested by the surveyor, highlighting a gap in the facility's procedures for addressing such issues.
Failure to Review and Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to ensure that a baseline care plan was reviewed with a resident and a copy or summary of the plan was provided within 48 hours of admission, as required by their policy. The resident, identified as R10, was admitted with diagnoses including chronic heart failure, weakness, unsteadiness on feet, and chronic kidney disease. Despite having a BIMS score indicating cognitive intactness, R10 reported not participating in the baseline care planning process and not receiving any information about it. The medical record lacked documentation of a signed baseline care plan, contrary to the facility's policy. Interviews with the Acting-Director of Nursing and Interim-Director of Nursing revealed that the facility had a process and policy for completing and reviewing baseline care plans, but it was not followed in this instance. The baseline care plan was supposed to be completed, reviewed with the resident, signed, and scanned into the medical record within two days of admission. However, this process was not adhered to, as evidenced by the absence of a signed care plan in R10's medical record. The Nursing Home Administrator was informed of this deficiency, but no further information was provided.
Failure to Implement Pressure Injury Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as R100, who was at risk for pressure injuries. R100 was admitted with diagnoses including diabetes, muscle weakness, and urinary incontinence. The resident's Admission Minimum Data Set (MDS) indicated a risk for pressure injuries, triggering a Care Area Assessment (CAA) for Pressure Injury. Despite this, the resident's care plan did not include any measures for the prevention of pressure injuries, even though the Braden Scale for Predicting Pressure Ulcer Risk had documented the resident as being at risk on multiple occasions. During the survey, it was observed that R100 was using a pressure reduction mattress and had her heels elevated, yet no pressure injuries were noted. However, the Director of Nurses (DON) confirmed that there was no care plan in place for the prevention of pressure injuries, which was a requirement according to the facility's policy. This deficiency was discussed with the Nursing Home Administrator and the DON during the exit meeting, but no additional information or corrective actions were provided at that time.
Deficiency in ADL Care for Two Residents
Penalty
Summary
The facility failed to provide necessary ADL services for two residents, R8 and R31, who were dependent on staff for assistance. R8, who has severe cognitive impairment and multiple medical conditions, was observed with long, dirty fingernails and was scratching open wounds on her leg and head. Despite being dependent on staff for all ADLs, there was no documentation of nail care being performed, and staff were unsure if nail care was included in R8's care plan. The facility's policy indicated that nail care should be done on bath days, but this was not consistently documented or performed for R8. R31, also with severe cognitive impairment and multiple diagnoses, was observed with contracted fingers and long, dirty fingernails that were touching the palms, posing a risk of injury. R31's care plan included interventions for skin integrity but did not specifically address nail care. Staff indicated that nail care was typically done on bath days, but there was no evidence that this was being completed for R31. The hospice aide noted the need for nail care but did not perform it, and there was no documentation of nail care being done on scheduled bath days. The surveyor's observations and interviews with staff highlighted a lack of consistent nail care for both residents, despite the facility's policy and the residents' dependency on staff for ADLs. The interim DON and NHA were informed of the concerns, but no immediate corrective actions were documented in the report. The deficiency in providing adequate ADL care, specifically nail care, was evident in the facility's failure to ensure proper hygiene and prevent potential harm to the residents.
Deficiency in Weekend Activities Program
Penalty
Summary
The facility failed to provide an ongoing, individualized, and meaningful activities program designed to meet the residents' interests and support their physical, mental, and psychosocial well-being for two residents reviewed for activities. Both residents expressed a desire to participate in organized group activities on the weekends, but the facility did not offer such activities. Instead, the facility provided activity packets and options to watch sports or church services on television, which did not meet the residents' needs for group interaction. The facility's activity calendars for March, April, and May confirmed the lack of organized group activities on weekends. Additionally, the facility did not complete Section F of the Minimum Data Set (MDS) assessment for one of the residents, which is intended to document the importance of activities and the types of activities the resident would enjoy. The Life Enrichment Director acknowledged the deficiency in weekend activities and the incomplete MDS section, attributing the lack of weekend activities to staffing limitations. The Director of Nursing and the Nursing Home Administrator were informed of these concerns, but no policy regarding resident activities was provided to the surveyor.
Failure to Implement Timely Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate assistance devices and interventions were in place to prevent accidents for a resident identified as high risk for falls. The resident was admitted to the facility after experiencing a fall with head trauma at a previous residence and was assessed as a high fall risk upon admission. Despite this, a falls care plan was not initiated until nearly two months later, on December 4, 2023. During this period, the resident experienced multiple falls, including an incident where the resident was lowered to the floor by staff after losing balance while attempting to prepare for a shower. The resident's care plan was not revised following subsequent falls on December 8 and December 12, 2023, which indicated a need for more frequent safety checks and encouragement to use the call light for assistance. The resident had a history of self-transferring and not using the call light, which contributed to the falls. Despite being reminded to call for assistance, the resident continued to self-transfer, leading to further incidents. The facility's failure to update the care plan and implement effective interventions contributed to the ongoing risk of falls. Interviews with staff revealed that the resident preferred to be independent and was generally compliant with using the call light in recent months. However, the lack of timely and appropriate interventions in the care plan following the initial and subsequent falls demonstrated a deficiency in the facility's approach to fall prevention for this high-risk resident. The surveyor noted these deficiencies and shared concerns with the facility's administration, highlighting the need for a more proactive approach to fall prevention and care plan management.
Deficiency in Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter had a valid medical justification for its continued use, appropriate monitoring, and care to maintain dignity. The resident, identified as R31, was admitted with a Foley catheter but lacked a diagnosis or justification for its use, as well as orders for monitoring or care instructions. Observations revealed that the catheter bag was not placed in a privacy bag, exposing it to view. The facility's policy required obtaining an order for the catheter, documenting its type, size, and indication for use, and involving the resident or responsible party in the care plan process, none of which were followed. The resident, R31, had multiple diagnoses, including anxiety disorder, dysphagia, and quadriplegia, and was on hospice care requiring consistent oxygen. Despite these conditions, there was no catheter care plan or interventions listed for the certified nursing assistant (CNA) to follow. The CNA reported emptying the catheter bag regularly but was unsure about changing the bag or cleaning the insertion site. The licensed practical nurse (LPN) confirmed the absence of catheter care orders in the resident's medical record and was uncertain about when the catheter and bag were last changed, suspecting that hospice might have handled it. The nursing home administrator was informed of these issues, but no immediate corrective actions were documented in the report.
Deficiency in Respiratory Care for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards for a resident requiring oxygen therapy. The resident, who has multiple diagnoses including chronic obstructive pulmonary disease and is on hospice care, was observed with unlabeled oxygen tubing and without protective coverings around the ears as per the facility's respiratory protocol. Additionally, there was no care plan in place for the resident's respiratory or oxygen use, and no specific orders for the care of oxygen supplies were documented. During the survey, it was noted that the resident's oxygen was running at 5 liters, but the nasal cannula was not properly positioned in the resident's nose. Staff interviews revealed a lack of clarity and consistency regarding the replacement and labeling of oxygen equipment. The interim DON acknowledged the need for labeling and regular replacement of oxygen tubing but was unsure of the standard practice. The CNA and LPN interviewed were also uncertain about the specific care requirements and procedures for the resident's oxygen use, indicating a gap in staff training and protocol adherence.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the accurate and safe administration of medication for two residents, R7 and R34, as observed during a medication pass. For R34, Hydrochlorothiazide 12.5 MG was not administered because it was not found in the medication cart, yet it was signed out as given on the Medication Administration Record (MAR). The Licensed Practical Nurse (LPN) responsible for administering the medication admitted to not finding it in the cart and thus not giving it, despite it being recorded as administered. Similarly, for R7, Voltaren gel was not administered because it had been used up the previous day and not reordered. The agency nurse involved in the medication pass acknowledged that the medication was not available and had not been reordered, yet it was signed out as administered by the LPN they were training. The facility's Acting Director of Nursing and Interim Director of Nursing confirmed that both medications were available in the Omnicell system and should have been administered, highlighting a failure in following the facility's procedures for medication administration and documentation.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring of psychotropic medications for two residents, leading to deficiencies in medication management. One resident, identified as R6, was prescribed Duloxetine for depression without a corresponding care plan or monitoring for depressive symptoms and side effects. Despite having intact cognition and no depressive symptoms according to their quarterly MDS, there was no documentation or specific monitoring in place to assess the effectiveness or side effects of the medication. The facility's staff, including CNAs and LPNs, were not aware of any specific monitoring requirements for R6, and the care plan lacked any mention of the antidepressant medication. Another resident, R37, was receiving Trazodone and Mirtazapine for anxiety and appetite, respectively, but there was no behavior monitoring to ensure the effectiveness of these medications. Although a care plan was eventually initiated, it was not specific to the anti-anxiety medication, and there was no documentation of behavior monitoring in the resident's TAR or MAR. Interviews with nursing staff revealed a lack of awareness and documentation regarding behavior monitoring, which was necessary to evaluate the effectiveness of the psychotropic medications. The facility's policy on psychoactive medication protocol was not adequately followed, as it required monitoring of medication side effects and documentation of target behaviors. The surveyor's findings highlighted the absence of specific care plans and monitoring for residents on psychotropic medications, which are essential to ensure the medications are necessary and effective. The facility's failure to implement these measures resulted in a deficiency in the medication regimen for the residents involved.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.11% during a survey. Three residents were affected by this deficiency. One resident did not receive Voltaren Gel as ordered, despite it being signed out on the Medication Administration Record (MAR). The agency nurse acknowledged that the gel was used up the previous day and not reordered, and it was revealed that the medication was available in the facility's Omnicell system but was not administered. Another resident did not receive Hydrochlorothiazide 12.5 mg, which was also signed out on the MAR. The LPN responsible for administering the medication stated that it was not found and therefore not given, although it was available in the Omnicell system. A third resident did not receive Amlodipine 10 mg, despite it being signed out as administered. During the medication pass, the surveyor observed that the medication was not included in the medication cup, although it was an active physician order. The surveyor confirmed with the nurse that the medication was not administered, leading to a discrepancy in the MAR. These incidents highlight a failure in the facility's medication administration process, as medications were either not reordered, not located, or not administered despite being available, and were inaccurately documented as given.
Resident Received Double Dose of Vancomycin Due to Transcription Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A resident, identified as R100, was admitted with a diagnosis that included status post right knee surgery. The resident had a physician's order for Vancomycin 125 milligrams for an infection in the right knee to be administered every three days. However, due to a transcription error, the order was duplicated, resulting in the resident receiving double the prescribed dose from April 12, 2024, to May 28, 2024. This error led to the administration of 16 extra doses of Vancomycin during this period. The issue was identified by a surveyor on May 28, 2024, and brought to the attention of the Nursing Home Administrator and Director of Nurses. Upon review, no negative effects from the extra doses were found in the resident's medical record.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to currently accepted professional principles, as well as failed to remove expired medications from medication carts. This deficiency was observed in 3 out of 5 medication carts/storage rooms. Specifically, the refrigerators in the 1st and 2nd floor medication storage rooms lacked temperature monitoring logs, which are necessary to ensure medications are stored within the appropriate temperature range. The surveyor noted the absence of a temperature log in the 2nd floor medication storage room and an incomplete log in the 1st floor medication storage room, with only a few dates filled out for the month of December. The Interim Director of Nursing confirmed that temperature logs were not being maintained and indicated that the facility would begin recording temperatures immediately. Additionally, the surveyor observed that a vial of insulin glargine, which was opened on March 15, 2024, was still being stored in the medication cart beyond its recommended use-by date. According to Diabetes.org, once opened, insulin vials should be stored at room temperature for no more than 28 days before being discarded. Despite this guideline, the insulin glargine was still present in the medication cart during the surveyor's review on May 29, 2024. The surveyor confirmed that the resident had an active physician order for insulin glargine to be administered at bedtime for diabetes management.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data, including the date, resident census, and total actual hours worked by RNs, LPNs, and CNAs, was posted daily. This deficiency was observed when a surveyor noted that the nursing postings at the facility's main entrance were dated 5/30/2024, despite the survey being conducted on 6/3/2024. The surveyor's attempt to locate the responsible scheduler revealed a lack of clarity regarding who was responsible for updating the postings on weekends or when the scheduler was not present. During interviews, the scheduler admitted to forgetting to post the data on 5/31/2024 and expressed uncertainty about who updated the postings in their absence. The Nursing Home Administrator (NHA) was also unsure about the process for updating postings when the scheduler was unavailable. This lack of a clear procedure led to the failure to update the nurse staffing information daily, potentially affecting all 44 residents in the facility.
Inaccurate Documentation of Resident's Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately documented throughout the medical record. The resident, who was under hospice care and had a terminal prognosis, was documented as a Full Code in the electronic medical record (EMR) despite having a Do Not Resuscitate (DNR) order since 10/02/22. This discrepancy was discovered when the resident's family member found the resident nonresponsive and informed the nurse on duty of the DNR status. The nurse, following the EMR, indicated the resident was a Full Code and required the family member to sign another DNR form. The facility's Administrator confirmed the inconsistency in the resident's code status documentation during an interview.
Failure to Prevent Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident who was admitted without a pressure injury was properly assessed and monitored, resulting in the development of a stage 3 pressure injury. The resident, who had diagnoses including Alzheimer's Disease, diabetes mellitus, chronic kidney disease, and transient ischemic attack, was admitted with no pressure injuries and was assessed with a BIMS score indicating severe cognitive impairment. Despite being identified as at risk for pressure injuries, the resident's care plans did not include any interventions to prevent the development of pressure injuries. The Braden Scale completed on admission indicated no risk, but no further skin assessments were documented until the wound was identified by a wound care specialist, who noted the injury was over seven days old. The resident was later transferred to the hospital for an unrelated reason and did not return to the facility. The facility's policy required weekly skin checks and documentation, but there was no evidence of these checks being completed for the resident. Progress notes and other medical records did not indicate any skin concerns or pressure injuries from admission until the wound was identified. Interviews with staff, including an LPN and the ADON, revealed a lack of awareness of the pressure injury, and the facility was unable to provide additional information regarding the development of the injury. The administrator confirmed the absence of further information prior to the wound's identification.
Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to complete a thorough investigation of a fall involving a resident (R5) who was admitted with diagnoses of Alzheimer's Disease, unsteadiness on feet, and muscle weakness. The resident, who was severely cognitively impaired and required moderate assistance with most activities of daily living, was found sitting on the floor in her room without socks or shoes. The fall was unwitnessed, and the resident reported that she had slipped down onto the floor. Despite this incident, the facility did not document the fall in the Incident Report, and numerous attempts to contact the nurse on duty at the time were unsuccessful. The Assistant Director of Nursing (ADON) confirmed that she had made multiple calls and texts to the nurse but had not received any response. The Administrator also confirmed that there was no additional information or investigation conducted by the risk committee regarding the fall. This lack of documentation and follow-up investigation is a violation of the facility's policy, which requires a thorough review and root cause analysis by the Interdisciplinary Team (IDT) for any fall incidents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R3) who was frequently incontinent of bowel and bladder. R3, who was moderately cognitively impaired and required maximum assistance for toileting, was observed on multiple occasions with wet pants and a saturated brief. Despite the facility's policy to check and change residents every two to three hours, R3 was left in wet clothing for an extended period, from at least 12:40 PM to 2:10 PM, without being checked or changed. The CNA responsible for R3 admitted to not checking him for incontinence since 10:00-10:30 AM, citing understaffing as the reason for the lapse in care. This neglect was confirmed by the Assistant Director of Nursing (ADON), who acknowledged that residents should be checked every two hours. The observations and interviews revealed that R3's incontinence care was not managed according to the facility's protocol, putting the resident at risk for skin issues and potentially a urinary tract infection. The resident's care plan specifically required cleaning after every incontinence episode and monitoring for signs of urinary tract infection, which was not adhered to. The CNA's failure to check and change R3 in a timely manner, combined with the facility's staffing issues, directly led to the deficiency in care.
Failure to Perform Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during incontinence care for one resident. During an observation, a CNA did not change her gloves after removing the resident's soiled clothing and before putting on a clean brief. The CNA continued to use the same gloves to clean the resident's perineal area, apply a clean brief, and change the resident's oxygen tubing. This action was against the facility's hand hygiene policy, which mandates glove removal and hand hygiene before moving from a soiled body site to a clean body site and immediately after glove removal. The resident involved was admitted with diagnoses of right hemiplegia, Alzheimer's disease, and dementia, and was assessed as moderately cognitively impaired. The resident required maximum assistance for toileting and was frequently incontinent of bowel and bladder. The CNA acknowledged her mistake immediately after the observation, and the Assistant Director of Nursing confirmed that the CNA should have changed her gloves between handling the soiled brief and the clean brief.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 766 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waukesha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avina Of Pewaukee | 0.1 mi | ★★★★★ | 5 | 0 |
| Complete Care At Kensington | 1.4 mi | ★★★★★ | 5 | 0 |
| Aria Of Waukesha | 2.7 mi | ★★★★★ | 20 | 1 |
| Complete Care At Care Age | 5.8 mi | ★★★★★ | 1 | 0 |
| Franciscan Woods | 6.4 mi | ★★★★★ | 22 | 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.