Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Luther Manor during CMS and state inspections, most recent first.
Two residents at risk for pressure injuries did not receive consistent prevention and wound care services as required by facility policy and provider orders. For one resident with multiple comorbidities and severe cognitive impairment, weekly skin checks were frequently undocumented before a facility-acquired stage 3 sacral pressure injury developed, and subsequent sacral and hip wounds were not always treated as ordered, with delays in entering wound care orders and repeated failures to implement the wound care provider’s specific dressing and topical treatment recommendations. For another resident who developed bilateral heel pressure injuries, staff had not floated the heels prior to injury, weekly skin checks were often missing, repositioning was infrequent per interviews and observation, and a pressure-relieving air mattress was not provided until several days after the heel wounds were discovered.
Opened insulin vials and eye drops were found without the required opening dates in a medication room and on a med cart. Surveyors observed multiple open Lantus and Lispro vials for several residents in the refrigerator, plus open Latanoprost and Ofloxacin eye drops for two residents on the rehab unit, all lacking the date opened despite facility policy and pharmacy guidance requiring dating and beyond-use labeling.
Failure to process a resident grievance: A cognitively intact resident with CHF, CKD, COPD, depression, anxiety, spinal stenosis, and chronic pain reported upsetting interactions with a CNA and asked that the CNA not care for them. An LPN acknowledged the resident’s request, but no grievance was completed, and survey review found no documentation of a thorough investigation or resolution.
A resident with anxiety disorder and multiple chronic conditions had a PRN lorazepam order for anxiety that had no stop date. Survey review found the PRN psychotropic order exceeded the 14-day limit without physician documentation explaining why a longer duration was appropriate or specifying a duration, despite the DON and provider referencing prior fills and a psychiatry follow-up with no med changes.
The facility failed to provide adequate supervision and timely fall-related care plan updates for two residents with fall histories. One resident with Parkinson’s disease, dementia, orthostatic hypotension, and repeated falls had multiple falls, delayed care plan revisions, and observed interventions not in place, including a missing wheelchair seat belt and absent doorway stop sign. Another resident with hemiplegia and hemiparesis fell while attempting to toilet independently, and the fall interventions were not added to the care plan until several days later.
A resident with ESRD receiving hemodialysis did not receive documented post-dialysis assessment or vital signs, and the facility’s dialysis communication forms contained only pre-dialysis vitals with no entries from dialysis staff. Staff also documented bruit/thrill checks on the TAR even though the resident had a chest access port, not an AV fistula. Interviews confirmed the facility expected pre- and post-dialysis monitoring and communication, but the record lacked evidence that this occurred.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with significant mobility impairments filed a grievance after a CNA refused to transfer them to bed near shift change, resulting in a one-hour wait. The facility failed to complete the grievance investigation, did not interview the involved CNA, and did not document or communicate the resolution, leaving required forms unsigned and the process incomplete.
A resident with CMV was prescribed IV ganciclovir, but a nurse incorrectly transcribed the order, entering an early stop date. This led to the resident missing five doses of the antiviral medication before the error was discovered by the Infection Disease Clinic.
A facility failed to obtain a written consent for the psychotropic medication Seroquel prescribed to a resident with Delusional Disorder. Despite the resident's cognitive intactness, the facility did not secure a signed consent from the activated HCPOA when the medication was first prescribed. The absence of a facility policy for obtaining consents contributed to this oversight, and verbal consent was only obtained after the surveyor's inquiry.
The facility failed to report three abuse allegations involving two residents and a resident-to-resident altercation to the State Survey Agency within the required timeframe. The incidents included a bruise of unknown origin, an alleged rape, and a physical altercation. Delays were attributed to a transition period and lack of awareness by the Nursing Home Administrator.
The facility failed to thoroughly investigate allegations of abuse and resident-to-resident altercations. A resident alleged being raped and sustaining blunt force trauma, but the facility did not collect necessary statements or report the incident to the State Survey Agency. In another case, one resident punched another, but the facility's investigation was incomplete and delayed. The facility's policy on reporting and investigating incidents was not followed, and the Nursing Home Administrator acknowledged the deficiencies.
A resident with mental health needs did not receive the specialized psychiatric rehabilitation services recommended by a PASARR Level 2 evaluation. The facility failed to update the resident's care plan and coordinate with the interdisciplinary team to address these needs. Staff interviews revealed a lack of awareness and action regarding the required services, and the facility did not submit a timely PASARR screen, delaying the identification of the resident's needs.
A resident admitted with a Level I PASARR for a short stay remained in the facility beyond the 30-day exemption without a timely Level II PASARR evaluation. Diagnosed with multiple mental health disorders, the resident required specialized psychiatric services, which were not identified until a delayed PASARR update. The facility's oversight was linked to communication issues and the activation of the resident's HCPOA.
A facility failed to update a resident's care plan to include specialized psychiatric rehabilitation services as recommended by a Level II PASARR evaluation. The resident, with multiple mental health diagnoses, was not provided with person-centered interventions tailored to their needs. Despite the facility's policy requiring regular care plan reviews, the resident's plan remained unchanged, focusing on perceived negative behaviors without addressing underlying causes.
A resident admitted with a left femur fracture and other conditions experienced inadequate discharge planning, despite a goal to transition to a less restrictive environment. The facility failed to provide consistent planning, with no documented referrals or updated assessments, leading to the resident's distress and dissatisfaction. Interviews revealed a lack of active efforts to facilitate a safe discharge, and the nursing home administrator was unaware of the deficiencies.
A resident with multiple health conditions, including hemiplegia and chronic kidney disease, did not receive timely incontinence care as per their care plan, resulting in a saturated incontinence product. The CNA admitted to not checking the resident every two hours, as required. The LPN/UM confirmed the expectation for two-hour checks, and the deficiency was reported to the NHA and DON.
A resident with a history of trauma and multiple mental health diagnoses did not receive an individualized care plan or specialized psychiatric rehabilitation services as required. The facility failed to update the resident's care plan with person-centered interventions, and the Medication Administration Record was not accurately completed. Interviews revealed the resident's distress and dissatisfaction with the care provided, highlighting the facility's failure to address the resident's mental health needs effectively.
A resident with severe protein malnutrition and dementia developed a pressure injury that was not promptly assessed or treated, leading to its worsening. The facility failed to adjust the care plan to address the resident's nutritional needs and implement preventative measures, resulting in a finding of immediate jeopardy.
A resident with severe protein malnutrition and dementia experienced significant weight loss and developed a stage 4 pressure injury due to the facility's failure to conduct comprehensive nutritional assessments and develop an individualized care plan. Despite the resident's poor oral intake and dementia, the facility did not revise the care plan or implement speech therapy recommendations, resulting in a finding of immediate jeopardy.
The facility failed to accurately report COVID-19 cases during an outbreak, with two residents not included in the infection line list. Additionally, there was a lack of signage to indicate the outbreak, and CNAs were observed not following proper hand hygiene practices during meal service. The Infection Preventionist admitted to oversight in correlating cases with the outbreak, and the Director of Nursing confirmed the expectation for proper hand hygiene, which was not met.
The facility failed to develop comprehensive care plans for residents, including those with smoking habits, chronic conditions, and medication needs. This led to deficiencies in addressing their medical, nursing, and psychosocial needs, as confirmed by interviews with facility staff and surveyor observations.
The facility failed to ensure medication storage rooms were free of expired medications, affecting two units. Expired sodium chloride irrigation bottles, Systane lubricant eye drops, and tear eye drop advance bottles were found. Additionally, a bottle of Lantus insulin for a resident was opened and not dated, with another expired bottle present. The responsibility for checking expired medications was shared among staff, but the facility did not ensure compliance with protocols.
The facility failed to monitor and reduce doses of psychotropic medications for several residents, as required by its policy. Residents on antipsychotic medications did not receive necessary AIMS assessments, and there was no evidence of attempted dose reductions for some residents. The facility's electronic system failed to trigger required assessments, and the lack of documentation was acknowledged by staff.
The facility failed to report two allegations of abuse or neglect to the State Survey Agency within the required timeframe. An accusation of abuse involving a resident was not reported to the NHA promptly, and a resident-to-resident altercation was not reported to the State Survey Agency. Additionally, the facility did not investigate or report an injury of unknown origin involving another resident who returned from hospitalization with a femur fracture.
The facility failed to thoroughly investigate allegations of abuse and injuries of unknown origin for two residents. One resident returned from hospitalization with a femur fracture, but no investigation was conducted. Another resident was involved in an abuse allegation and a resident-to-resident altercation, both of which were inadequately investigated and reported. The facility did not provide sufficient documentation or follow proper procedures, leading to deficiencies in handling these incidents.
The facility failed to provide required written transfer notifications to three residents and their representatives when they were hospitalized. The nursing staff, responsible for these notifications, did not complete them, and the State Ombudsman was not informed. This oversight affected residents who were transferred due to changes in condition or medical issues.
A facility failed to accurately document a resident's behaviors in the MDS, despite progress notes indicating occurrences of wandering, agitation, and resistiveness. The MDS inaccurately reflected that these behaviors were not exhibited, and interviews revealed that the social worker responsible for the section did not complete it correctly, highlighting a need for staff training.
The facility failed to update care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident's care plan was not revised after a Foley catheter was removed, another's did not reflect the use of a condom catheter, and a third's lacked documentation for a compression sleeve. Staff interviews confirmed the oversight, despite facility policies requiring timely updates.
The facility did not act on pharmacist recommendations for two residents regarding the use of Seroquel without an appropriate diagnosis. Despite repeated pharmacy reviews noting this issue, no follow-up actions were taken by the facility, and the recommendations were not addressed by the physician.
A resident with a history of heart disease and hypertension did not receive six doses of Plavix due to medication unavailability, despite the facility having an Omnicell system. Staff interviews revealed inconsistencies in following procedures for obtaining medications, with the DON acknowledging the availability of Plavix in the Omnicell and indicating a need for further investigation.
A facility failed to ensure a CNA received the required 12 hours of continuing competence training, affecting 90 residents. CNA-M, hired in 2022, only completed 4.5 hours. The training department, responsible for tracking CNA training, overlooked CNA-M, as confirmed by interviews with the DON and NHA.
The facility failed to provide adequate care for pressure injuries, resulting in deterioration and severe outcomes for three residents. One resident's pressure injury progressed from a deep tissue injury to a Stage 4 wound due to delayed lab tests and incomplete antibiotic treatment. Another resident developed multiple pressure injuries, leading to an amputation. A third resident's pressure injury worsened due to lack of comprehensive assessment and care plan updates.
The facility failed to implement care plans for residents at high risk for falls, leading to significant injuries. One resident, admitted with a fractured hip, was assessed as high risk but had no care plan for falls, resulting in another fracture. Another resident experienced an unwitnessed fall with inadequate investigation and no new interventions. The facility did not follow its fall prevention policies, contributing to these deficiencies.
A resident was allegedly choked by a CNA, but the incident was not reported to the State Survey Agency or local law enforcement within the required timeframes. Another resident overheard the incident and attempted to report it, but the call light was not answered until hours later. The facility's report was submitted late, and the social worker could not explain the delay or lack of law enforcement notification.
The facility failed to thoroughly investigate abuse allegations involving two residents. In one case, a resident reported being choked by a CNA, but the investigation lacked comprehensive witness statements and a physical assessment. In another case, a resident reported verbal abuse, but the facility did not follow up with all staff or collect resident statements. Both investigations were incomplete, lacking critical documentation and analysis.
A resident with a femur fracture did not receive timely follow-up care as per discharge instructions. The facility lacked a policy for managing appointments, leading to delayed and missed orthopedic consults. Despite training to improve scheduling, the resident's care did not align with professional standards or their care plan.
Failure to Provide Consistent Pressure Ulcer Prevention and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and treatment consistent with its own policies and professional standards for two residents with, or at risk for, pressure injuries. For one resident on hospice with multiple comorbidities including vascular dementia, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and functional dependence, the facility did not consistently complete and document weekly skin checks as required by policy and medical orders in the weeks preceding the development of a facility-acquired stage 3 sacral pressure injury. In the eight weeks prior to the initial sacral wound, weekly skin checks were undocumented on four occasions, and when showers were refused, there was not always documentation of a completed skin assessment or of re-approach attempts, despite the DON’s expectation that skin checks still occur and be documented. After the sacral pressure injury developed, the facility did not consistently implement and document wound treatments as ordered by the physician and wound care provider. There were delays of two days in entering and starting treatment orders for new bilateral hip stage 2 pressure injuries, and on at least one day no treatment was documented as completed for these new wounds. For the sacral wound, staff documented using Santyl when the wound provider had changed the treatment to Leptospermum (Medihoney), and there were multiple days when the sacral wound was only cleansed and covered without the ordered topical agent due to Santyl being unavailable and the new order not yet implemented. When the left hip pressure injury reopened, the wound provider’s treatment recommendations were not entered as medical orders for several days, resulting in that wound going without the ordered daily treatments from the time of reopening until new orders were entered. Throughout the subsequent months, the facility repeatedly failed to promptly translate the wound provider’s treatment recommendations into active medical orders and to carry them out as written. Treatment changes ordered by the wound provider on several visits (including changes from Medihoney to Iodosorb, and later to Iodosorb plus calcium alginate, and then to Medihoney plus Xeroform) were implemented late, omitted, or altered by staff. For example, staff continued to use Iodosorb and calcium alginate for both the sacral and hip wounds after the provider had ordered Medihoney and Xeroform, and for a period treated the left hip with Medihoney and calcium alginate instead of Medihoney and Xeroform as ordered. During these periods of noncompliance with the wound care plan, the sacral wound increased in size and developed a high percentage of eschar, and the left hip wound increased in size. A second resident developed avoidable, facility-acquired bilateral heel pressure injuries. Contributing factors identified in the report included failure to float the heels prior to the development of the injuries, multiple missing weekly skin checks both before and after the heel wounds were discovered, and infrequent repositioning as evidenced by staff interview and observation. An air mattress, despite being a pressure-relieving intervention referenced in facility policy, was not provided until five days after the heel pressure injuries were identified. These actions and omissions show that the facility did not consistently implement its wound prevention program requirements for weekly skin checks, pressure redistribution surfaces, and regular turning and repositioning for this resident at risk for pressure injuries. Across both residents, the facility’s own policies required weekly skin checks documented in the EMR, prompt initiation of skin event assessments when abnormalities were noted, and implementation of individualized interventions in the care plan to prevent pressure injury development and promote healing. The report documents that these processes were not reliably followed: weekly skin checks were missed or undocumented, refusals were not consistently followed by re-approach and documentation, and wound care orders from the wound provider were not always entered accurately or in a timely manner. As a result, residents at risk for pressure injuries did not consistently receive the ordered and policy-required preventive care and wound treatments intended to prevent new pressure injuries and to promote healing of existing wounds.
Opened Medications Not Dated When Opened
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles because multiple opened medications were not dated when opened. In the 2500 unit medication room, surveyors observed two open Lantus insulin vials for R29, one open Lantus vial for R4, one open Lantus vial for R28, one open Lispro vial for R28, and one open Lispro vial for R56 in the refrigerator, and none of these vials had the date they were opened. The facility’s policy required multi-dose vials to be relabeled with a beyond-use date 28 days after opening unless otherwise specified, and the pharmacy list identified Lantus and Lispro as expiring 28 days after opening. On the rehabilitation unit medication cart, surveyors found an open bottle of Latanoprost 0.005% eye drops for R49 and an open bottle of Ofloxacin 0.3% eye drops for R38 that were not dated when opened. The label on the Latanoprost bottle stated it expired 42 days after opening, and the label on the Ofloxacin bottle stated a start date of 10/12/25, but neither bottle had the opening date documented. The facility policy required opened multi-dose vials and medications to include the date opened and the applicable expiration date.
Failure to Process Resident Grievance
Penalty
Summary
The facility failed to address and resolve a grievance conveyed on behalf of one resident, who was cognitively intact and able to make self understood and understand others. The resident had diagnoses including diastolic CHF, CKD stage 3, COPD, major depressive disorder, generalized anxiety disorder, lumbar spinal stenosis, and chronic pain syndrome. The facility’s grievance policy stated that complaints or grievances should be promptly resolved and investigated, including review of the complaint, interviews, record review, and root-cause analysis when indicated. The resident reported concerns about a CNA after an interaction in which the resident asked the CNA to place a handbag back on the doorknob after it fell to the floor, and the CNA responded that it was not her job. The resident stated the interaction was upsetting and caused crying, and asked that the CNA not be allowed in the room. The LPN manager later acknowledged the resident had said, “I don't want CNA-G to take care of me anymore,” but no grievance was completed. Surveyor review found no grievance filed on the resident’s behalf, no documentation of a thorough investigation, and no documented appropriate resolution. The social worker lead, DON, and NHA were informed of the concern, but no additional information was provided showing the grievance had been addressed through the facility’s grievance process.
PRN Psychotropic Order Lacked Required 14-Day Limit
Penalty
Summary
The facility did not ensure that a resident receiving a PRN psychotropic medication had an order limited to 14 days. Resident R9, who was admitted with diagnoses including diastolic CHF, CKD stage 3, COPD, major depressive disorder, generalized anxiety disorder, lumbar spinal stenosis, and chronic pain syndrome, had a Significant Change MDS showing a BIMS score of 13 and was coded as able to make self understood and understand others. The care plan identified the resident as using anti-anxiety medications, including PRN lorazepam, for anxiety disorder and included interventions to administer anti-anxiety medications as ordered, monitor for side effects and effectiveness each shift, and educate the resident and family about the risks and side effects of anti-anxiety medications. The physician order for lorazepam 0.5 mg by mouth every 12 hours as needed for anxiety had a start date and no end date. Survey review noted that the PRN psychotropic order was beyond 14 days without documentation from the physician or prescriber explaining why a longer timeframe was appropriate or specifying a duration. During the survey, the DON stated she would look for documentation, and later reported that the provider said the order had been filled multiple times and referenced a psychiatry follow-up with no medication changes, but this did not provide a stop date or document a rationale for extending the PRN order beyond 14 days.
Delayed fall care plan updates and missing fall interventions
Penalty
Summary
The facility did not ensure adequate supervision and assistance to prevent accidents for two residents with a history of falls. One resident had diagnoses including Parkinson’s disease, dementia, orthostatic hypotension, cancer, and a history of falling, and was documented as cognitively intact but requiring substantial to maximum assistance for transfers. The resident was identified as high risk for falls and had multiple falls while at the facility. Survey review showed that after several falls, the resident’s care plan was not updated immediately, with some interventions added days later and one fall not reviewed and revised until 21 days after the event. During survey observations, fall-related interventions were not consistently in place, including a stop sign at the doorway and a seat belt for the wheelchair. After a fall on 10/24/25, the resident slid out of the wheelchair while eating in the dining room. The resident’s care plan was later updated to include locating the wheelchair with seat belt and ensuring proper positioning at the dining room table, but staff interviews indicated the wheelchair with seat belt had been out for repair and was not available at the time of the fall. Surveyor observations during the survey found the resident in the dining room without a seat belt in place, and the resident’s room did not have the stop sign intervention in place when observed. Staff interviews confirmed that the wheelchair and seat belt had been unavailable for an unknown period while being serviced. A second resident, admitted with hemiplegia and hemiparesis following cerebral infarction and a history of falling, had an unwitnessed fall on 8/2/25 after the resident’s husband placed the resident in the bathroom and the resident tried to use the restroom independently. The resident was found on the floor with the head under the sink and was alert and verbal. The resident’s fall-related care plan interventions were not added until 4 and 5 days later. Survey review documented that the facility did not revise the care plan timely after the fall, and no additional information was provided to explain the delay.
Dialysis Monitoring and Communication Deficiency
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required hemodialysis. The facility’s policy stated that residents receiving hemodialysis were to receive ongoing assessment before and after dialysis, monitoring for complications, and ongoing communication and collaboration with the dialysis facility. The resident, R51, was admitted with diagnoses including venous insufficiency and hypertensive chronic kidney disease stage 5/end stage renal disease and received dialysis every Tuesday, Thursday, and Saturday. R51’s December 2025 TAR documented monitoring of a hemodialysis access device for bleeding, infection, pain, and bruit/thrill every shift, with staff signing out the task as completed with a plus sign indicating bruit/thrill present. However, surveyor observation found that R51 did not have an atrioventricular fistula and instead had an access port in the upper right chest. During interview, an LPN stated the resident had a chest access site and staff did not change the dressing, only kept it clean and dry. Review of the dialysis communication forms in the resident’s binder showed only two forms, both containing pre-dialysis vital signs only. There was no documentation from dialysis staff and no facility documentation of assessment or vital signs after dialysis. Nursing staff stated the expectation was to complete pre- and post-dialysis vital signs and assessments and to document on the forms, but the record review found no evidence that post-dialysis assessments or vital signs were completed in the medical record or nursing progress notes. The LPN manager also stated she could not locate the missing communication forms and acknowledged the resident’s TAR contained documentation for bruit/thrill assessment despite the resident not having a shunt.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Properly Investigate and Resolve Resident Grievance
Penalty
Summary
A deficiency occurred when the facility failed to properly address and resolve a grievance submitted on behalf of a resident who was dependent on staff for mobility due to multiple fractures and hemiplegia. The resident, who was cognitively intact, reported that a CNA refused to transfer them from a wheelchair to bed, citing the request was too close to shift change, resulting in the resident waiting an hour for assistance. The grievance documentation was incomplete, lacking a clear resolution and missing required signatures from the grievance official, DON, and NHA. Further investigation revealed that the social worker responsible for handling the grievance could not recall the details of the incident, was unable to locate additional information, and did not have statements from the CNA involved. There was no evidence that the CNA was interviewed or that the results of the grievance resolution were communicated to the resident or the NHA. The facility's policy required immediate attempts to resolve complaints, escalation if unresolved, and thorough investigation, including interviews with involved staff, none of which were documented in this case.
Medication Order Transcription Error Resulting in Missed Antiviral Doses
Penalty
Summary
A deficiency occurred when a resident admitted with cytomegaloviral disease (CMV) was prescribed intravenous ganciclovir, with instructions from the hospital to continue the medication twice daily and later changed to once daily by the Infectious Disease Clinic, with no specified stop date. The order was incorrectly transcribed by a registered nurse, who entered a stop date of 12/18/24 for the ganciclovir, despite the Infectious Disease Clinic's instructions that the medication should continue until the resident's follow-up appointment on 12/23/24. As a result, the resident did not receive five doses of the antiviral medication between 12/18/24 and 12/23/24. The error was discovered when the Infection Disease Clinic inquired about the early discontinuation of the medication. Facility documentation and interviews confirmed that the order transcription was not accurate, and the medication was stopped prematurely. The facility's investigation acknowledged the medication administration error and confirmed that the resident missed several doses due to the incorrect transcription of the physician's order.
Failure to Obtain Written Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain a written consent explaining the risks and benefits of the psychotropic medication Seroquel for a resident diagnosed with Delusional Disorder. The resident, who was prescribed Seroquel initially at 12.5 mg twice daily and later increased to three times daily, did not have a signed consent from the activated Health Care Power of Attorney (HCPOA). The facility was unable to provide documentation of the competency evaluation for the resident, and there were discrepancies in the activation dates of the HCPOA. Despite the resident's cognitive intactness as indicated by a Brief Interview for Mental Status (BIMS) score of 14, the facility did not ensure that the consent process was completed when the medication was first prescribed. The surveyor's review of the electronic health record confirmed the absence of a written consent for the antipsychotic medication, including the reason for its use, alternative treatments, and associated risks and benefits. The Nursing Home Administrator acknowledged the lack of documentation and the absence of a facility policy for obtaining consents for required medications. The Medical Records staff confirmed that verbal consent was obtained after the surveyor's inquiry, but acknowledged that the consent should have been obtained at the time of the initial prescription. The facility did not provide additional information to explain the oversight in obtaining the necessary consent.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report three allegations of abuse involving two residents and one resident-to-resident altercation to the State Survey Agency within the required timeframe. The first incident involved a resident who had a bruise of unknown origin, which was later diagnosed as cellulitis. Although the initial report was submitted, the Misconduct Incident Report was delayed by over a month due to a transition period involving the former Director of Nursing. The Nursing Home Administrator acknowledged the delay but provided no additional information to justify the late submission. The second incident involved a resident who alleged rape, with the initial report submitted late and the Misconduct Incident Report delayed. Additionally, the resident called the police to report an assault, but the facility failed to submit the required reports to the State Survey Agency. The Nursing Home Administrator was unaware of the police report and attributed the oversight to a transition period, admitting to a lack of timely reporting. The third incident involved a resident-to-resident altercation where one resident punched another. The initial report was submitted, but the Misconduct Incident Report was delayed by over a month. The Nursing Home Administrator was unaware of the delay until informed by the surveyor and acknowledged the concern. No further information was provided by the facility regarding the delay in reporting.
Inadequate Investigation of Abuse and Altercation Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and resident-to-resident altercations, as evidenced by the incomplete Facility Reported Incidents (FRIs) and Misconduct Incident Reports. In the case of a resident, who alleged being raped and sustaining blunt force trauma, the facility did not collect all necessary staff and resident statements, nor did it perform a root cause analysis. Additionally, the facility did not report the incident to the State Survey Agency or complete a thorough investigation, despite the resident contacting the police about the alleged assault. In another incident involving two residents, one resident reportedly punched another in the face and cursed at them. The facility's investigation was inadequate as it lacked staff and resident statements, did not notify law enforcement, and failed to establish a pattern of behavior or agitation. The Misconduct Incident Report was only completed after the surveyor brought the issue to the facility's attention, indicating a lack of timely and comprehensive investigation. The facility's policy on reporting and investigating alleged incidents of abuse, neglect, exploitation, and mistreatment was not followed, as evidenced by the incomplete investigations and lack of corrective actions. The Nursing Home Administrator was unaware of some allegations and acknowledged the deficiencies in the investigation process, but no further information or corrective actions were provided at the time of the survey.
Failure to Implement PASARR Recommendations for Resident with Mental Health Needs
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screen and Resident Review (PASARR) Level 2 determination into the assessment, care planning, and transitions of care for a resident with mental health needs. The resident, identified as R58, was admitted with diagnoses including depression, anxiety, and other mental health disorders. Despite the PASARR Level 2 evaluation recommending specialized psychiatric rehabilitation services, the facility did not update the resident's care plan to include these services. The facility's policy requires coordination with the PASARR program to ensure residents with mental disorders receive appropriate care. However, the facility did not follow through with this policy for R58. The resident's care plan was not updated with person-centered interventions, and the interdisciplinary team (IDT) did not develop a plan to address the specialized psychiatric needs. Interviews with staff, including the social worker, psychologist, and nursing staff, revealed a lack of awareness and action regarding the specialized services required for R58. The deficiency was further highlighted by the facility's failure to submit a new Level 1 PASARR screen in a timely manner, which delayed the identification of the need for specialized services. The nursing home administrator and other staff members were not familiar with the requirements for specialized psychiatric rehabilitation services, and there was no documentation of these services being developed or implemented for R58. This lack of action and coordination resulted in the resident not receiving the necessary care to address their mental health needs.
Failure to Complete Timely PASARR for Resident
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) for a resident, identified as R58, who was admitted with a Level I PASARR indicating a stay of less than 30 days. However, R58 remained in the facility beyond this period without a resubmitted or updated PASARR, which should have triggered a Level II PASARR evaluation. This oversight was not addressed until 10/16/24, when a new Level I PASARR was submitted, revealing that R58 required specialized psychiatric rehabilitation services. R58 was admitted with diagnoses including Depression, Fracture of Left Femur, and other conditions. Despite having a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness, R58 was diagnosed with several mental health disorders by a psychologist and psychiatrist, including Adjustment Disorder with Depressed Mood, Major Depressive Disorder, and Psychotic Disorder with Delusions. The facility's policy required a Level II PASARR evaluation within 40 days of admission if the resident stayed beyond the 30-day exemption, which was not completed in a timely manner. The breakdown in the PASARR process was attributed to a lack of communication and oversight, particularly concerning the activation of R58's Health Care Power of Attorney (HCPOA). The Admissions Director, Social Worker, and MDS Coordinator were involved in the process, but the necessary PASARR updates were delayed. The Nursing Home Administrator acknowledged the concern when it was brought to their attention by the surveyor, highlighting the facility's failure to adhere to its own policies and state regulations regarding PASARR screenings.
Failure to Update Resident Care Plan with Specialized Psychiatric Services
Penalty
Summary
The facility failed to update and implement a comprehensive person-centered care plan for a resident, identified as R58, to meet their psychosocial needs. The care plan did not incorporate the Level II PASARR recommendations, which indicated the need for specialized psychiatric rehabilitation services. Despite the determination that R58 required these services, the care plan remained unchanged, lacking person-centered interventions tailored to the resident's needs. R58 was admitted with multiple diagnoses, including depression and anxiety disorders, and was receiving psychotropic medications. The resident's care plan was not updated to reflect the need for specialized psychiatric rehabilitation services, which were recommended to address R58's mental illness. The facility's failure to revise the care plan meant that interventions were not aligned with the resident's current needs, as identified in the comprehensive assessment. The facility's policies require that care plans be reviewed and revised after each comprehensive and quarterly MDS assessment, as well as when a resident experiences a status change. However, R58's care plan had not been updated since the determination of the need for specialized services, and the facility did not provide documentation to clarify the activation date of the resident's Health Care Power of Attorney. The care plan focused on perceived negative behaviors without addressing the underlying causes or facilitating the resident's independence and emotional health.
Failure in Discharge Planning for Resident
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, identified as R58, who was admitted with a left femur fracture and other medical conditions including depression, severe protein-calorie malnutrition, polyneuropathy, and anemia. Despite having a goal to discharge to a less restrictive environment, the facility did not provide consistent and active discharge planning since the resident's admission. The resident's care plan initially indicated a desire to return home, but was later revised to discharge to the most appropriate level of care without clear documentation of progress or actions taken to achieve this goal. The facility's policy required a comprehensive, person-centered care plan aligned with the resident's discharge goals, but this was not effectively implemented. The resident's Minimum Data Set (MDS) indicated cognitive intactness and a discharge plan to the community, yet no updated assessments or active discharge planning were documented. The social worker's notes revealed inconsistent communication and planning, with no evidence of referrals made to assess the resident's suitability for assisted living or other long-term care facilities, despite the resident's expressed desire to leave the facility. Interviews with the resident and facility staff highlighted the resident's distress and dissatisfaction with the current living situation, as well as a lack of documented efforts to facilitate a safe and appropriate discharge. The nursing home administrator acknowledged the concern but was unaware of the lack of active discharge planning. The social worker mentioned an outside agency's involvement in referrals, but there was no documentation to support this claim, indicating a significant gap in the discharge planning process.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that a resident, identified as R150, who is unable to carry out activities of daily living, received the necessary services to maintain good grooming. On a specific date, R150 was not provided with incontinence care every two hours as required by the care plan, resulting in the resident being observed with a saturated incontinence product. The facility's policy mandates that residents who are incontinent of bladder or bowel receive appropriate treatment to prevent infections and restore continence to the extent possible. R150 was admitted to the facility with multiple diagnoses, including diabetes mellitus, chronic kidney disease, and hemiplegia following a cerebral infarction. The resident's care plan, initiated and revised earlier in the year, included interventions such as cleaning the peri-area with each incontinence episode and checking for incontinence every two hours. Despite these interventions, the surveyor observed that R150's incontinence product was saturated with urine, and the resident had not been checked every two hours as required. During interviews, the CNA responsible for R150 admitted to not checking the resident every two hours on the day of the observation, acknowledging it was her fault. The LPN/UM confirmed that the expectation is for residents to be checked every two hours according to their care plan. The Nursing Home Administrator and Director of Nursing were informed of the deficiency, but no additional information was provided to explain why the necessary services were not provided to R150.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services to a resident, identified as R58, to help achieve the highest possible quality of life. R58, who has a history of trauma, was not given an individualized plan of care to address this trauma. Despite a Level II PASARR screen indicating the need for specialized psychiatric rehabilitation services, the facility did not update R58's comprehensive care plan with person-centered interventions. The social worker did not assist R58 in identifying and preparing for alternate placement, and the facility lacked a policy for medically related social services. R58 was admitted with multiple diagnoses, including depression and anxiety, and was prescribed several psychotropic medications. However, the Medication Administration Record (MAR) was not accurately completed, failing to document behaviors or interventions related to R58's mental health needs. The facility's care plan for R58 was not person-centered and focused on perceived negative behaviors without addressing underlying causes or facilitating self-independence. The care plan had not been updated with new interventions since the determination of the need for specialized services. Interviews with staff and the resident revealed that R58 was experiencing significant distress, frequently refusing care, and expressing a desire to leave the facility. The social worker acknowledged the complexity of R58's case but did not complete a new trauma assessment after learning of past sexual trauma. The facility's failure to provide appropriate social services and update care plans contributed to R58's ongoing mental health crisis and dissatisfaction with the care received.
Failure to Prevent and Treat Pressure Injury
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent the development of pressure injuries and to promote healing for a resident identified as R62. R62 developed a pressure injury on the right buttock, which was not comprehensively assessed, and there was a delay in physician notification for treatment. The pressure injury worsened during this period, and by the time the wound physician assessed it, the injury was unstageable and required debridement. The facility did not conduct a comprehensive assessment of R62's risk factors, including severe protein malnutrition and decreased mobility, which contributed to the development of the pressure injury. R62 was admitted with severe protein malnutrition, dysphasia, and severe dementia, and was at risk for pressure injuries. Despite these risk factors, the facility did not adjust the care plan to address the resident's nutritional needs or implement preventative measures for pressure injuries. The resident experienced significant weight loss, which was not addressed in the care plan, and there was no comprehensive assessment of the resident's nutritional needs to promote wound healing. The facility's failure to promptly assess and treat the pressure injury, along with inadequate nutritional interventions, contributed to the decline in R62's condition. The facility's policy required a comprehensive assessment of residents to prevent pressure injuries, but this was not followed in R62's case. The interdisciplinary team met to discuss the new pressure injury but classified it as unavoidable without making necessary changes to the care plan. The facility did not notify the physician of the pressure injury's decline, and there were no changes in treatment until the wound physician's assessment. The lack of timely intervention and comprehensive assessment led to the finding of immediate jeopardy, indicating a serious risk of harm to the resident.
Failure to Maintain Nutritional Status Leads to Severe Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R62, maintained acceptable parameters of nutritional status, leading to severe weight loss and the development of a stage 4 pressure injury. R62 was admitted with severe protein malnutrition, dysphasia, and severe dementia, requiring assistance with eating. Despite these conditions, the facility did not conduct comprehensive nutritional assessments or develop an individualized plan of care. The resident's nutritional assessments did not include accurate weights or individualized interventions, and there was a lack of documentation regarding vitamins, mineral supplements, or high-calorie food options. R62 experienced significant weight loss, dropping from 130 lbs to 69.2 lbs, a 46.7% decrease, which contributed to the development of a stage 4 pressure injury and the resident being placed on hospice care. The facility's records showed inconsistencies in weight documentation, and the resident's family expressed disbelief in the recorded weights. Despite the resident's poor oral intake and the presence of dementia, the facility did not revise the plan of care to address these issues adequately. The resident's speech therapy recommendations were not implemented in the care plan, and there was no comprehensive assessment to identify causative factors for the severe weight loss. The facility's failure to provide adequate nutrition and conduct comprehensive assessments resulted in a finding of immediate jeopardy. The resident's nutritional assessments lacked a personalized approach, and there were no changes in the plan of care until mid-July, despite the resident's declining condition. The facility did not ensure that the resident's nutritional status was maintained within acceptable parameters, leading to severe weight loss and further health complications.
Inaccurate COVID-19 Reporting and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure accurate data collection and reporting during a COVID-19 outbreak, which led to deficiencies in their infection prevention and control program. The outbreak was initially identified when two staff members tested positive, followed by two residents. However, the infection line list did not accurately reflect all cases, as two residents who tested positive were not included. Additionally, the monthly infection rates were inaccurate, with residents being prescribed antibiotics without documented signs, symptoms, or diagnoses. The Infection Preventionist (IP) admitted to not correlating certain cases with the outbreak and failing to update the line list accordingly. Furthermore, the facility did not post visual alerts or signs to notify staff and visitors of the ongoing COVID-19 outbreak, as required by their own policies. This lack of communication could have contributed to the spread of the virus within the facility. The IP acknowledged the absence of signage and attributed it to oversight, as well as a lack of understanding of the correlation between the outbreak and the positive cases. In addition to the issues with infection reporting and communication, the facility was observed to have deficiencies in hand hygiene practices among CNAs during meal service. CNAs were seen not using hand hygiene appropriately, such as changing gloves without washing hands or using alcohol-based hand rub. The Director of Nursing (DON) confirmed the expectation for proper hand hygiene, but the observed practices did not align with these expectations. This failure in hand hygiene could potentially affect all residents in the facility.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. One resident, who was assessed as an independent smoker, did not have a care plan in place to address smoking safety needs and interventions. Despite being identified as a smoking resident, the facility did not document a person-centered comprehensive care plan for this resident's smoking habits. Another resident with chronic nosebleeds and diabetes did not have care plans addressing these conditions. The resident's medical records indicated a history of nosebleeds and a prescription for Afrin Nasal Spray, but no care plan was created to manage these nosebleeds or the resident's diabetes. The facility's failure to document care plans for these conditions was noted during interviews with the Unit Manager and the Director of Nursing, who acknowledged that such conditions should be care planned. Additional deficiencies were identified for residents using antipsychotic and antianxiety medications, specialized communication needs, and anticoagulant medication. One resident did not have a care plan for the use of antipsychotic and antianxiety medications, including non-pharmacological interventions and side effects monitoring. Another resident with communication deficits did not have a comprehensive communication care plan, despite being dependent on pen and paper for communication. Furthermore, a resident on anticoagulant medication and using a condom catheter did not have care plans addressing the use and monitoring of these interventions. These omissions were confirmed during interviews with facility staff and highlighted during the surveyor's exit meetings with the Nursing Home Administrator and Director of Nursing.
Expired Medications Found in Facility's Storage Rooms
Penalty
Summary
The facility failed to ensure that medication storage rooms were free of expired medications, affecting two medication storage rooms. During an inspection, a surveyor observed expired medications, including 0.9% sodium chloride irrigation bottles and Systane lubricant eye drops, in the 2900 unit medication storage room. Additionally, expired tear eye drop advance bottles were found in both the 2900 and 2700 unit medication storage rooms. The surveyor questioned the Medication Technician and the Director of Nursing (DON) about the responsibility for checking expired medications, and both indicated that it was a shared responsibility among all staff, particularly the night shift. Furthermore, the surveyor found a bottle of Lantus insulin for a resident in the 2700 unit medication storage room that was opened and not dated, along with another expired bottle of Lantus insulin. The DON confirmed that the protocol was to date insulin when opened and to consider it expired after 28 days, advising staff to verify with the pharmacy if unsure. Despite these protocols, the facility did not ensure that the medication storage rooms were free of expired medications, potentially affecting residents who may have eye drops ordered.
Deficiency in Monitoring and Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring and dose reductions for residents on psychotropic medications, as observed in four out of six resident medication reviews. Specifically, residents receiving antipsychotic medications did not have Abnormal Involuntary Movement Scale (AIMS) assessments completed to monitor for side effects. For instance, a resident with schizoaffective disorder and dementia was on routine antipsychotic medication, but there was no documentation of an AIMS assessment until after the surveyor's request. Similarly, another resident with Alzheimer's dementia and agitation was on Seroquel, yet no AIMS assessment was completed due to a failure in the facility's electronic system to trigger the assessment. Additionally, the facility did not attempt gradual dose reductions for certain residents on psychotropic medications. One resident receiving Cymbalta and Sertraline for depression had no documented evidence of attempted dose reductions, and the Director of Nursing acknowledged the lack of documentation. Another resident on Seroquel for nightmares also did not have a gradual dose reduction or psychiatric consult documented, as confirmed by the Infection Preventionist. The facility's policy on the use of psychotropic medications requires gradual dose reductions and AIMS assessments, but these were not consistently followed. The Nursing Home Administrator and Director of Nursing were informed of these deficiencies during the survey, but no additional information was provided to justify the lack of monitoring and dose reductions for the affected residents.
Failure to Report Abuse and Injury Incidents
Penalty
Summary
The facility failed to report two out of three allegations of abuse or neglect to the State Survey Agency within the required timeframe. Specifically, an accusation of abuse involving a resident, identified as R77, was not reported to the Nursing Home Administrator (NHA) within the required timeframe. The incident was known to the facility on one day but was not communicated to the NHA until the following day. The delay was attributed to a supervisor's belief that the incident was a result of a personal disagreement between two Certified Nursing Assistants, with no signs of abuse observed. Additionally, the facility did not report a resident-to-resident altercation involving R77 to the State Survey Agency. The altercation occurred when a CNA attempted to escort R77 to their room, resulting in R77 biting another resident who tried to assist. The incident was reviewed by the facility's Interdisciplinary Team (IDT), but it was determined that it did not meet the guidelines for reporting to the Department of Health Services. The Director of Nursing (DON) and the NHA acknowledged that the incident was not reported. Furthermore, the facility did not investigate or report an injury of unknown origin involving another resident, identified as R5, who returned from hospitalization with a femur fracture. The facility's NHA indicated that the fracture was idiopathic due to age and did not occur within the facility, thus no investigation or report was made to the State Agency. However, the NHA acknowledged the requirement to report injuries of unknown origin, and the facility failed to comply with this requirement.
Failure to Investigate Abuse Allegations and Injuries
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and injuries of unknown origin for two residents, R5 and R77. R5 returned to the facility from a hospitalization with a femur fracture, but the facility did not investigate the cause of this injury. The Nursing Home Administrator (NHA) indicated that the fracture was idiopathic due to age and did not occur within the facility, thus no investigation was conducted. However, the surveyor noted that the facility is required to investigate injuries of unknown origin, and the NHA acknowledged this requirement but did not provide any additional information or documentation of an investigation. For R77, an accusation of abuse was made, but the investigation was not thorough. The NHA interviewed the accused Certified Nursing Assistant (CNA) and the supervisor on duty but allowed the CNA to continue working with residents until the end of their shift and the start of a new shift the next day. There was a delay in preventing further potential abuse, and the NHA provided minimal education to the supervisor involved, with no evidence of broader staff education or resident interviews. The surveyor noted the lack of thorough investigation and documentation, as the provided resident interview sheet lacked dates, times, and signatures. Additionally, a resident-to-resident altercation involving R77 was not properly investigated or reported. The incident was documented in progress notes, but the required Department of Health Services Form was not submitted to the State Survey Agency. During the exit meeting, the NHA and Director of Nursing acknowledged the failure to report the incident and did not provide any investigation records. This lack of thorough investigation and reporting for both residents highlights deficiencies in the facility's handling of abuse allegations and injuries of unknown origin.
Failure to Provide Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notifications of transfer to the hospital for three residents, as required by their policy. Resident R5 was transferred to the hospital multiple times due to changes in condition, but neither R5 nor their representative received written notifications for these transfers. Additionally, the State Ombudsman was not informed. The Nursing Home Administrator (NHA) acknowledged that the nursing staff, who were responsible for providing these notifications, had not been completing them. Similarly, Resident R34 was transferred to the hospital for sepsis and transverse colitis, but there was no evidence that a transfer notice was provided to R34 or their representative. Resident R32 also experienced a change in condition that necessitated a hospital transfer, yet no transfer notice was documented. The NHA confirmed that the nursing staff had not completed the required transfer notices for these residents, and no additional information was provided to explain the oversight.
Inaccurate MDS Documentation for Resident Behaviors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the behaviors of a resident, identified as R77, during the assessment period. The Quarterly MDS for R77, with an assessment reference date of 6/19/24, incorrectly documented that the resident did not exhibit certain behaviors, such as physical behavioral symptoms directed towards others, other behavioral symptoms not directed towards others, rejection of evaluation or care, and wandering. However, a review of progress notes during the look-back period indicated that these behaviors did occur and were treated with PRN medication as necessary. R77 was admitted to the facility with diagnoses including degenerative disease of the nervous system, unspecified dementia with agitation and anxiety, generalized anxiety disorder, major depressive disorder, and wandering. The progress notes documented multiple instances of behaviors such as wandering, agitation, and resistiveness, which were managed with PRN medications like Lorazepam. Despite these documented behaviors, the MDS inaccurately reflected that these behaviors were not exhibited by R77. Interviews with facility staff revealed that the MDS Coordinator did not complete R77's quarterly MDS and directed the surveyor to speak with the social worker, who was unavailable. The Nursing Home Administrator acknowledged the discrepancies in the MDS and indicated that the social worker did not complete the assessment correctly, suggesting a need for training on MDS completion. No further explanation was provided for the inaccuracies in the MDS documentation.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to update the comprehensive person-centered care plans for three residents, which led to deficiencies in meeting their medical, nursing, and psychosocial needs as identified in their comprehensive assessments. Resident R64's care plan was not updated after the removal of a Foley catheter, despite observations and interviews confirming the absence of the catheter. The care plan continued to document the presence of the catheter and related interventions, indicating a lack of timely revision by the facility staff. Resident R49's care plan was not updated to address the use of a condom catheter, and Resident R29's care plan was not revised to include the use of a Tenashape compression sleeve ordered for edema management. The facility's policy requires care plans to be reviewed and revised after each comprehensive and quarterly MDS assessment and upon any status change, but these updates were not made, leading to discrepancies between the residents' current needs and their documented care plans. Interviews with facility staff, including the Unit Manager and the Director of Nursing, revealed an acknowledgment of the oversight in updating the care plans. The facility's policy outlines the responsibility of designated staff, such as the MDS Coordinator and Unit Managers, to ensure care plans reflect current resident needs and communicate changes to all involved staff. However, these procedures were not followed, resulting in the identified deficiencies.
Failure to Address Pharmacist Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to act upon pharmacist recommendations for two residents, R62 and R77, during their monthly drug regimen reviews. For R62, who was admitted with Alzheimer's dementia, pharmacy reviews conducted in June and July 2024 noted the absence of an appropriate diagnosis for the use of the antipsychotic medication Seroquel. Despite these findings, there was no documentation in the medical record indicating that the physician acknowledged or acted upon the pharmacist's recommendations. The Nursing Home Administrator provided the surveyor with the pharmacy review notes, but no explanation was given for the lack of physician response. Similarly, for R77, who was admitted with multiple diagnoses including unspecified dementia with agitation and anxiety, the pharmacy review notes from April to August 2024 consistently highlighted the absence of an allowable diagnosis for the use of Seroquel. Despite repeated recommendations from the pharmacist, these concerns were not addressed, and there was no follow-up action taken by the facility. The Director of Nursing confirmed that the recommendations were not acted upon, and no additional information was provided to explain the oversight.
Failure to Administer Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Plavix, an anticoagulant medication. The resident, who has a history of type 2 diabetes mellitus, atherosclerotic heart disease, and essential hypertension, did not receive six doses of Plavix over a period of approximately two weeks. The facility's policy requires immediate action when medications are unavailable, including notifying the physician and obtaining alternative treatment orders. However, the medication was not administered on multiple occasions due to reasons such as 'on order' and 'await pharmacy delivery,' despite the facility having an Omnicell system for accessing medications. Interviews with facility staff, including a Certified Medication Assistant (CMA), Licensed Practical Nurse (LPN), and the Director of Nursing (DON), revealed inconsistencies in following the established protocol for obtaining medications from the Omnicell. The CMA indicated they would call the pharmacy and seek assistance from a nurse, while the LPN and DON confirmed that medications should be retrieved from the Omnicell. The DON acknowledged that Plavix was available in the Omnicell and indicated a need to investigate why the medication was not administered, suggesting potential training issues with staff or agency workers. The deficiency was communicated to the Nursing Home Administrator and the DON, but no further information was provided regarding the failure to administer the medication as prescribed.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that one of five Certified Nursing Assistants (CNAs) reviewed received the required 12 hours of continuing competence training. This deficiency potentially affects 90 residents who could receive care from the CNA. CNA-M, who was hired on October 31, 2022, only received 4.5 hours of continuing competence training. During the survey on September 10, 2024, the surveyor reviewed CNA-M's training record and confirmed the shortfall in training hours. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that the training department is responsible for tracking and ensuring CNAs complete their required training hours. However, CNA-M was overlooked, and no additional information was provided to explain why the facility did not ensure the completion of the required training hours.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and promote the healing of pressure injuries for three residents. One resident, identified as having a deep tissue injury, did not receive timely lab tests, and the prescribed antibiotic was not administered for the full duration. The facility also failed to implement a treatment plan for a Stage 1 sacrum pressure injury, which later progressed to Stage 2. The care plan for this resident was not updated until 14 days after the pressure injury was identified. Another resident, who was at risk for pressure injuries, developed multiple facility-acquired pressure injuries, including an unstageable right heel pressure injury that became infected, leading to hospitalization and an above-the-knee amputation. The facility did not update the resident's care plan or implement necessary interventions to prevent the deterioration of the pressure injuries. A third resident developed a Stage 2 pressure injury that was not comprehensively assessed until it had declined to an unstageable wound. The facility did not revise the resident's care plan or involve a dietician when the new pressure injury developed. The resident was observed not receiving incontinence care or repositioning as care planned. The facility's policy and procedure for pressure ulcer care did not include evaluation of the stage or description of the wound bed, contributing to the deficiencies observed.
Failure to Implement Fall Prevention Care Plans
Penalty
Summary
The facility failed to implement care plans for residents at high risk for falls, leading to significant injuries. One resident, admitted with a fractured left hip, was assessed as high risk for falls but did not have a care plan addressing this risk. Despite multiple documented instances of restlessness and attempts to get out of bed unassisted, no fall prevention interventions were implemented. This resident eventually fell and sustained a right hip fracture, requiring hospitalization. The facility's records did not show any RN assessment after the fall, and the care plan was never updated to include fall prevention measures. Another resident, also at high risk for falls, experienced an unwitnessed fall resulting in a right intertrochanteric fracture. The investigation into this fall was inadequate, lacking a head-to-toe assessment, staff statements, and a root cause analysis. Despite the resident's high fall risk, no new interventions were implemented following the fall. Observations during the survey revealed that the resident's call light was not within reach, and the resident was not in a low bed, contrary to the facility's fall prevention protocols. The facility's policies require comprehensive assessments and care plans for residents at risk of falls, but these were not followed. The lack of appropriate care plans and post-fall assessments contributed to the residents' injuries. The facility's failure to adhere to its fall prevention policies and procedures resulted in significant deficiencies in the care provided to these residents.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R3, in a timely manner to the State Survey Agency and local law enforcement. On April 17, 2024, an allegation was made that a certified nursing assistant (CNA) choked R3. This incident was not reported to the state survey agency within the required 2-hour timeframe for serious bodily injury, nor was local law enforcement notified immediately. The facility's policy requires that all alleged incidents of abuse, neglect, exploitation, and mistreatment be reported promptly, but this protocol was not followed in this case. R3, who has a medical history including Alzheimer's Disease, Dementia with Psychotic Disturbance, and other conditions, was reportedly involved in an incident where another resident, R4, overheard verbal and physical abuse. R4 reported hearing R3 choking and later yelling about being choked. Despite R4's immediate attempt to report the incident by using the call light, it was not answered until several hours later by the next shift. The facility's report to the State Survey Agency was submitted late, and it lacked documentation of the time the facility was made aware of the incident or when the administrator was notified. The social worker responsible for submitting the Facility Reported Incident (FRI) could not recall why the report was delayed or why law enforcement was not notified. The Nursing Home Administrator acknowledged the concern but could not provide additional information. The failure to report the incident within the required timeframes and to notify law enforcement constitutes a deficiency in the facility's compliance with reporting and investigation guidelines.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse involving two residents, R3 and R4. For R3, an incident was reported where R3 was allegedly choked by a CNA. The investigation was incomplete as it lacked statements from all potential witnesses, including other residents and staff members. Additionally, there was no documentation of a head-to-toe physical assessment of R3, and local law enforcement was not notified. The facility's report did not include a root cause analysis or a comprehensive collection of evidence, such as statements from the accused CNA and the nurse on duty. R4 reported overhearing an altercation involving R3 and a CNA, including sounds of physical abuse and verbal threats. Despite R4's detailed account, the facility's investigation did not capture all relevant staff and resident statements. The investigation was further compromised by the absence of a BIMS and PHQ-9 assessment for R3, which could have provided insight into R3's mental status and ability to recall the incident. The social worker responsible for the investigation could not provide explanations for these omissions. In a separate incident involving R4, the facility again failed to conduct a thorough investigation. R4 reported verbal abuse and neglect by a CNA, but the facility's investigation lacked follow-up with several staff members who did not respond to initial contact attempts. There were also no resident statements collected to assess if there were prior concerns with the CNA involved. The facility's documentation did not demonstrate a comprehensive effort to gather all necessary information to address the allegations adequately.
Failure to Ensure Timely Follow-Up Care for Resident
Penalty
Summary
The facility failed to ensure that a resident received timely follow-up care as per hospital discharge instructions and professional standards of practice. The resident, who was admitted with multiple diagnoses including Alzheimer's Disease and a right intertrochanteric femur fracture, was instructed to have an orthopedic consult within six weeks post-discharge. However, the consult did not occur until nearly three months later. Additionally, the resident was supposed to return for a repeat x-ray one month after the initial consult, but there is no documentation that this appointment was attended. Furthermore, a subsequent orthopedic appointment was scheduled but not attended, with no documentation explaining the absence. The facility lacked a policy and procedure for managing resident appointments, which contributed to the oversight. The Health Information Manager acknowledged discrepancies in the scheduling and follow-up of the resident's appointments, citing issues with appointment availability and escort provision. Despite a training session conducted in March 2024 to address timely appointment scheduling, the resident's care was not aligned with the comprehensive person-centered care plan or the resident's choices, as evidenced by the missed and delayed appointments.
What surveyors are citing around you — mapped
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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 779 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Milwaukee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Anne's Salvatorian Campus | 1.2 mi | ★★★★★ | 2 | 0 |
| Lutheran Home | 3.1 mi | ★★★★★ | 0 | 0 |
| Congregational Home, Inc. | 3.4 mi | ★★★★★ | 0 | 0 |
| St Camillus Health Center | 4.4 mi | ★★★★★ | 0 | 0 |
| Bradley Estates Nursing And Rehab Llc | 4.6 mi | ★★★★★ | 40 | 0 |
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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.