Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Meadowbrook At Chetek during CMS and state inspections, most recent first.
Infection Prevention and Control Failures: Staff did not consistently follow EBP, hand hygiene, or equipment cleaning practices. An RN and LPN performed wound care on a resident with chronic wounds without PPE and without EBP signage posted, staff transferred another resident with a Hoyer lift without PPE, a lift was reused without being sanitized between residents, an RN did not sanitize hands after removing gloves between medication administrations, and residents were not offered hand hygiene before meals.
A facility failed to provide adequate behavior monitoring for five residents receiving psychotropic meds for anxiety, depression, insomnia, and bipolar disorder. Physician orders and care plans required staff to document the number of episodes of targeted behaviors, but TARs for each resident showed only checkmarks instead of episode counts. A CNA stated all residents had the same behavior task during the shift, and the DON said, "I don't know what happened there."
A resident with CVA, dysphagia, aphasia, and moderate cognitive impairment was denied an advanced diet unless she ate in the dining room for supervision, despite preferring to eat in her room. She frequently refused pureed meals, had significant weight loss and malnutrition, and staff confirmed she could have a minced diet with supervision. The ST also stated the resident and family were not educated on the risks and benefits of regular-texture foods, and no consent was obtained for eating regular foods in her room without supervision.
A resident with an open surgical wound and wound vac to the left thigh, plus a laceration to the 5th left toe, did not have an EBP care plan in place. The IP and DON both stated the resident should have been on EBP, and the IP acknowledged the care plan missed this information.
Care Plan Not Updated for Refusal of Dentures, Meals, and Tube Feedings: A resident with CVA, dysphagia, aphasia, and moderate cognitive impairment had significant weight loss, but the comprehensive care plan did not address refusal to wear dentures, refusal of pureed meals, refusal to go to the dining room, or refusal of scheduled G-tube feedings. Survey observations and staff interviews confirmed the resident often stayed in bed during meals, disliked the pureed diet, and declined tube feedings because they caused nausea, while the RD documented poor intake and tube feeding refusal as contributing to the weight loss.
Medication administration did not meet professional standards for two residents. An RN gave nasal sprays to a resident with congestion and rhinorrhea without first cueing the resident to blow the nose, and an LPN gave nasal spray to another resident without doing so. The LPN also administered meds via a PEG tube for a resident with CVA, dysphagia, and aphasia without checking tube measurement at the insertion site or aspirating gastric contents, instead relying on auscultation for air bubbling.
A resident’s fluid intake exceeded a 2500 mL/day restriction on multiple occasions without MD notification, a resident with stroke-related dysphagia and weight loss did not receive speech therapy using dentures as recommended, and hospital discharge orders for a resident’s left foot laceration and podiatry follow-up were omitted after readmission. Staff and the DON confirmed missing documentation, incomplete therapy implementation, and unaddressed discharge instructions.
Omitted Left Foot Treatment and Missed Podiatry Follow-Up: A resident returned from the hospital with discharge instructions for nursing treatment to a laceration on the left 5th toe and a podiatry follow-up for fractures of the 4th and 5th toes, but the facility did not enter the foot treatment orders or schedule the podiatry appointment. Staff were unsure about any left foot wound or treatment, and surveyors observed a darkened area and bruising on the toes with no dressing or bandage in place.
Improper catheter bag placement and lack of staff intervention: A resident with a Foley, a resident with a suprapubic catheter, and another resident with a Foley were observed with catheter drainage bags placed in wheelchair seats or entangled in a wheelchair wheel instead of below the bladder. Staff were present during the observations, but no intervention occurred for the residents whose bags were in the wrong location, despite care plans directing that catheter bags and tubing remain below the bladder at all times.
Nephrostomy Tubing Placed Above Kidney Level: A resident with bilateral nephrostomy tubes was observed with the tubing routed up and over the back of a wheelchair and placed in a pouch above kidney level, contrary to facility policy requiring drainage bags to remain below the kidneys. The resident had a history of UTIs, kidney calculus, CKD, hydronephrosis, neurogenic bladder, and sepsis, and the care plan directed that the catheter bag and tubing be kept below bladder level at all times. The DON and CNA both stated this placement was not appropriate.
The facility failed to prevent multiple significant medication errors when staff did not consistently verify medications against orders, left a med cart unattended, and did not remove discontinued drugs from circulation. A resident with orthostatic hypotension was given another resident’s Oxycontin ER and Amlodipine and required Narcan and hospitalization. Another resident with rib fractures received a discontinued opioid instead of the current pain medication. A hospice resident prescribed Lorazepam oral concentrate was repeatedly given tablet form and later received a dose after the drug was discontinued. Additional errors included a wrong Tacrolimus dose due to transcription error, a resident receiving another resident’s Atorvastatin, and a resident ingesting another resident’s gabapentin, clonidine, and Vitamin D after bedside medication cups were mixed up for two residents with the same initials.
A resident with orthostatic hypotension and a neurocognitive disorder received another resident’s medications, including Oxycontin ER and Amlodipine, from a licensed nurse, leading to administration of Narcan and hospital evaluation where the resident was found markedly orthostatic and required IV fluids and transfer to another hospital. Despite the facility’s abuse prevention policy defining possible neglect as failure to provide necessary goods or services to avoid harm, the DON reported that the incident was not reported to the state agency and the required 5-day investigation was not submitted on time, citing that it was the nurse’s first medication error and that there were no noted signs or symptom effects.
The facility failed to thoroughly investigate and promptly correct an initial opioid medication error, allowing additional serious medication errors to occur. A resident with rib fractures received a discontinued opioid that had not been removed from circulation. Subsequently, another cognitively intact resident with orthostatic hypotension and Lewy body neurocognitive disorder was given another resident’s medications, including Oxycontin ER and Amlodipine, and required Narcan, ED care, and hospital transfer. A cognitively intact hospice resident with COPD, chronic pancreatitis, and anxiety, ordered Lorazepam oral concentrate, instead received the wrong dosage form (tablet) on multiple occasions and later received the medication again after it had been discontinued, as it was not removed from circulation. These errors occurred despite existing policy requiring verification of medication labels against orders and after management became aware of the first error but before all licensed nurses were educated.
Two residents were affected when the facility failed to follow its own policy for controlled substance destruction and discontinuation. For one resident, a discontinued Pregabalin (Lyrica) 50 mg order was not destroyed promptly and was documented as destroyed by only one nurse instead of two licensed staff. For another resident, Lorazepam ordered as an oral concentrate for terminal anxiety was logged as 0.5 mg tablets, and the controlled substance log showed doses being administered after the medication had been discontinued. The DON and ADON acknowledged awareness of these medication errors, while an RN described a destruction process involving a drug buster and two nurse signatures that was not followed in these instances.
Two residents did not receive medications in accordance with physician orders and labeling requirements. One hospice resident with COPD, chronic pancreatitis, and generalized anxiety disorder was ordered Lorazepam oral concentrate for terminal anxiety but was repeatedly given tablet doses instead, and the drug continued to be administered after it was discontinued. In a separate case, an RN was found using an unlabeled morphine oral solution bottle marked only with a handwritten number, later identified as belonging to a resident, and confirmed that this medication had been administered multiple times without proper labeling or resident identification.
The facility did not accurately report direct care staffing data to CMS via the PBJ system, resulting in underreported weekend staffing levels. Although management and HR staff stated that weekend staffing was consistent with weekdays, a review revealed that hours worked by staff who left employment before data was pulled were omitted from PBJ submissions. This led to the facility being flagged for low weekend staffing, potentially affecting all residents.
A resident with upper limb monoplegia and COPD, requiring assistance with mobility, was found unable to reach their call light, which was wrapped around a bedside rail. The resident reported that staff frequently left the call light out of reach after transfers, despite care plan instructions and facility policy requiring accessibility to minimize fall risk. The DON confirmed staff were aware of the resident's limitations and the need for the call light to be within reach.
A resident with multiple medical conditions and existing pressure injuries did not receive wound care as ordered by the physician. During observed care, an RN failed to perform hand hygiene, did not follow the prescribed wound care steps, and omitted the application of required treatments, resulting in a deficiency in both infection control and adherence to professional standards.
Two residents were not adequately protected from accident hazards: one with severe cognitive impairment and high fall risk was left unsupervised in the bathroom, resulting in a fall, while another resident who vapes was not properly assessed or care planned for independent smoking, despite facility policy requiring such evaluation.
A resident requiring dialysis did not receive consistent pre- and post-dialysis assessments as required by facility policy and the care plan. Staff failed to document vital signs, weight, or inspection of the dialysis access site before or after dialysis treatments, and the DON confirmed that there was no established process for these assessments. The resident reported that vital signs were only sometimes checked after dialysis, and records showed only weekly documentation unrelated to dialysis sessions.
Staff failed to follow infection control protocols, including proper hand hygiene during wound and personal care, use of PPE for a resident with open wounds, and correct handling of a urinary catheter bag, which was repeatedly observed on the floor. These lapses involved multiple residents with complex medical needs and were not in accordance with facility policies.
The facility failed to follow its food storage and labeling policies, leading to multiple unlabeled and potentially expired food items in the walk-in refrigerator and resident kitchenette. The Dietary Manager and staff admitted to not labeling items with open dates, and expired items were found. The Nursing Home Administrator was unaware of any foodborne illnesses but acknowledged the deficiency after being informed by the Dietary Manager.
A facility failed to return a deceased resident's trust funds to the POA or family within 30 days, as required by policy. The resident's account showed a positive balance, but no conveyance was documented. A family member reported the facility refused to refund the balance, citing an outstanding debt. The NHA was unsure about the balance, and the Accounts Receivable Specialist claimed all accounts are usually settled within 30 days, highlighting a lapse in policy adherence.
Two residents experienced falls that were not immediately reported to the physician, violating the facility's policy. One resident with Alzheimer's disease fell and was not reported until a day later, while another resident with dementia had two unwitnessed falls, with no documentation of physician notification. The DON was unaware of the incidents until observing injuries.
Two residents in an LTC facility did not receive proper assessments following falls, as required by the facility's fall management policy. One resident, with severe cognitive impairment, was not thoroughly assessed after a fall, and the incident was not reported to hospice or family until the next day. Another resident, with dementia, experienced falls without documented assessments, and the DON was unaware of the incidents until observing facial bruising. These deficiencies highlight a failure in maintaining residents' well-being and communication protocols.
The facility failed to implement new fall interventions for three residents at risk for falls. One resident fell and had a planned intervention not added to their care plan. Another resident experienced two falls with no new interventions implemented. A third resident's care plan was not updated after a fall. The DON acknowledged the oversight.
The facility failed to ensure proper hand hygiene and use of hair nets in food service. A CNA entered the kitchen without a hair net, and a Dietary Cook handled food without changing gloves or using hand hygiene after touching unclean items. The Dietary Manager confirmed these practices were against facility policy.
A facility failed to follow physician orders to schedule a follow-up oncology appointment for a resident with a potentially metastatic lesion. The admission checklist process was not effectively executed, and the necessary information was not communicated to the Social Services Assistant responsible for scheduling. Staff interviews revealed confusion and a lack of timely action, resulting in the resident not receiving the required follow-up care.
The facility failed to evaluate hazards related to the use of an oscillating percussion vest for a resident with quadriplegia and high aspiration risk. The resident was observed alone during vest treatments, and staff did not consistently follow physician orders for post-treatment checks. The care plan lacked details on supervision during vest use, and no assessment was conducted to ensure the resident's safety while unsupervised.
A resident with epilepsy, cerebral palsy, and functional intestinal disorder received medication via G-tube without proper verification of tube placement. The LPN used an outdated method of injecting air and listening for noise, which is no longer the standard of practice. The facility's policy still included this outdated practice, leading to the deficiency.
The facility failed to maintain an effective infection prevention and control program. Staff did not perform proper hand hygiene during medication administration for a resident with severe cognitive impairment, and droplet precautions were removed prematurely for a COVID-19 positive resident due to a miscalculation of isolation days.
Infection Prevention and Control Failures
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program by not consistently using PPE for Enhanced Barrier Precautions, not sanitizing a mechanical lift between resident uses, not completing proper hand hygiene, and not offering hand hygiene to residents before meals. The report states these failures were identified through observation, interview, and record review and involved multiple residents and staff members during wound care, transfers, medication administration, and dining room routines. R23 was admitted with diagnoses including malignant neoplasm of the tongue, a stage 3 sacral pressure ulcer, and venous ulcers of the lower extremities. The surveyor observed RN C and LPN D enter R23's room and perform wound care on open leg wounds without donning PPE before or during the treatment. No EBP signage was posted outside the room at the time of the observation. Later, the same staff stepped outside the room and donned PPE after discussing that R23 had been in the facility more than 30 days and that the wounds were chronic. RN C stated that they had just realized R23 had been in the facility more than 30 days and was not sure whether all residents are placed on EBP only after 30 days. The DON was unable to provide evidence or an explanation for the lack of signage or PPE use before wound care. The surveyor also observed CNA R and LPN D transfer R4 with a Hoyer lift without PPE despite EBP signage outside the room. In another observation, CNA J and CNA G used a Hoyer lift to transfer R3, who was on EBP for a Foley catheter, then left the lift uncleaned before it was used to transfer R15. RN Q was observed administering nasal spray and eye drops to R72 while doffing gloves and reapplying clean gloves without sanitizing hands between tasks. In the dining room, staff did not offer hand hygiene to four residents who self-propelled to meals on two separate observations, with 17 residents present each time.
Incomplete behavior monitoring for residents receiving psychotropic medications
Penalty
Summary
The facility did not ensure residents were free from unnecessary psychotropic medication use because it did not provide adequate drug monitoring for 5 of 5 residents reviewed for unnecessary medication reviews. For each of the reviewed residents, physician orders or care plans required staff to document the number of times specific targeted behaviors occurred, but the Treatment Administration Records (TARs) showed only checkmarks indicating that a behavior occurred rather than the required number of episodes. R2 received Hydroxyzine HCl 25 mg daily for anxiety disorder and Trazodone HCl 50 mg daily for insomnia. Orders required documentation of the number of episodes of behaviors such as nervousness, restlessness, sweating, increased heart rate, difficulty sleeping, trouble concentrating, crying, tearfulness, social isolation, changes in appetite, and mood swings. R2’s TAR documented only a checkmark instead of the number of behavior episodes. R5 received Risperidone 1 mg three times daily for depression, Buspirone 10 mg three times daily for anxiety disorder, Trazodone 100 mg daily for insomnia, and Duloxetine for major depressive disorder recurrent. Orders required documentation of the number of episodes of crying, tearfulness, social isolation, changes in appetite, mood swings, or difficulty sleeping, but the TAR again used only a checkmark. R9 received Bupropion HCl 300 mg daily, Sertraline HCl 100 mg daily plus Sertraline HCl 50 mg daily for a total of 150 mg, and Trazodone HCl 100 mg daily for insomnia. Orders required documentation of the number of episodes of crying, tearfulness, social isolation, changes in appetite, mood swings, or difficulty sleeping, but the TAR showed only a checkmark. R45 received Buspirone HCl three times daily for generalized anxiety disorder, and R11 received Seroquel 50 mg daily for bipolar disorder. Their orders also required documentation of the number of episodes of targeted behaviors, but their TARs likewise showed checkmarks instead of episode counts. During interview, a CNA stated all residents had the same behavior task with a selection of behaviors completed during the shift, and the DON stated, "I don't know what happened there."
Resident’s Diet Advancement Restricted by Dining Location and Lack of Education
Penalty
Summary
The facility did not ensure that one resident could exercise her rights without interference, coercion, discrimination, or reprisal when it limited her access to an advanced diet unless she ate in the common dining area instead of in her room, which was her preference. The resident had diagnoses including CVA, dysphagia, and aphasia, and had a BIMS score of 9/15 indicating moderate cognitive impairment. She had significant weight loss since admission, a mini nutrition score indicating malnutrition, and documentation showed frequent meal refusal and low intake. During the review period, pureed meals were repeatedly observed untouched at her bedside, and the resident stated she did not like the food and had requested toast that was not provided. Record review and interviews showed the resident’s diet advancement was tied to supervision in the dining room because of safety concerns, with staff stating she could have a minced diet if she ate in the cafeteria where she could be monitored. The speech therapist confirmed the resident could have an advanced diet but needed supervision due to pocketing food and choking risk, and acknowledged the resident had the right to eat in her room with assistance. The speech therapist also stated the facility did not have staff to sit with her in her room, and no education had been provided to the resident or family about the risks and benefits of eating regular-texture foods. Staff reported the resident’s family brought in regular foods such as hamburgers and donuts, and the speech therapist confirmed no risk/benefit consent had been obtained for the resident choosing regular-texture foods in her room and/or without staff supervision.
Failure to Include EBP in Care Plan for Resident With Surgical Wound and Toe Laceration
Penalty
Summary
The facility did not develop and implement a comprehensive person-centered care plan for a resident with an open surgical wound with a wound vac to the left thigh and a laceration to the 5th left toe. The resident was readmitted after a surgical procedure to the left hip/thigh, and the record showed the wound vac was in place along with the toe laceration, which would warrant Enhanced Barrier Precautions (EBP). However, the care plan reviewed on 05/19/26 did not include an EBP care plan related to infection prevention. During interviews, the Infection Preventionist stated that wounds, catheters, feeding tubes, history of MDROs, and nephrostomies would warrant EBP, and acknowledged that R15 should have been placed on EBP and that it was missed. The DON also stated that wounds, chronic/open wounds, catheters, and PEG tubes might warrant EBP and agreed that the resident with a surgical wound, wound vac, and laceration requiring treatment should have been on EBP. An LPN stated the wound vac was scheduled to be removed and that standard precautions, EBP, gown, and gloves would be used if removing it.
Care Plan Not Updated for Refusal of Dentures, Meals, and Tube Feedings
Penalty
Summary
The facility did not ensure R10’s comprehensive care plan was reviewed and revised to address several ongoing issues affecting intake and nutrition. R10 was admitted with diagnoses including cerebral infarction, dysphagia, and aphasia, had a BIMS score of 9/15 indicating moderate cognitive impairment, and made own healthcare decisions. R10 had physician orders for gastric tube feedings twice daily and experienced a 10.05% weight loss since admission. Survey observations between 05/18/2026 and 05/21/2026 showed R10 not wearing dentures during or between meals, remaining in bed during meals, and at times having an untouched pureed meal with an emesis bag nearby. R10 told the surveyor that tube feedings made her nauseous and that she often refused them, did not like the pureed diet, and did not want to get out of bed to go to the dining room to eat. Staff interviews and record review showed the care plan did not include interventions for R10’s refusal to wear dentures, refusal to eat meals, refusal to go to the dining room for meals, or refusal of tube feedings. RN Q stated R10 often declined tube feedings because they made her feel nauseous and that she received scheduled ondansetron prior to meals/feedings; RN Q also stated the only other intervention was for R10 to go to the main dining area to receive an advanced diet and close supervision during meals. CNA O stated R10 only wore dentures when family was present and that R10 would refuse pureed food because she did not like it. The RD documented poor intake, refusal of most meals and tube feedings, and noted that R10’s weight loss was due to poor intake and tube feeding refusal. The DON confirmed there were no interventions on the comprehensive care plan addressing R10’s refusal to wear dentures, eat in the dining room, eat pureed meals, or remain compliant with scheduled tube feedings.
Medication Administration and Tube Placement Verification Deficiencies
Penalty
Summary
The facility did not ensure services provided met professional standards for medication administration for 2 of 4 residents reviewed. For R72, who was admitted with diagnoses of congestion, nasal crusting, and rhinorrhea, RN Q administered saline nasal 3% and Ipratropium Bromide nasal solution 0.03% on 05/19/2026 without first cueing or assisting the resident to blow the nose or clear the nasal passages. The DON stated staff should ask residents to blow their nose prior to administering nasal sprays. For R10, who was admitted with diagnoses including cerebral infarction, dysphagia, and aphasia and had physician orders for Jevity tube feedings via gastric tube twice daily, LPN M prepared to administer medications through the PEG tube on 05/19/2026. The surveyor observed LPN M unclamp the PEG tube, inject approximately 30 cc of air, and auscultate over the epigastrium for bubbling, but not check the tube measurement at the insertion site or aspirate for gastric contents before administering medications. The same morning, LPN M administered Fluticasone Propionate nasal suspension in both nostrils without having R10 blow the nose first. The DON stated the practice had changed to checking the PEG tube measurement at the insertion site and, if needed, aspirating gastric contents, and stated nurses should not use auscultation for gastric air bubbling as the only means of checking PEG tube placement.
Failure to Follow Physician Orders for Fluids, Speech Therapy, and Discharge Instructions
Penalty
Summary
The facility failed to notify the physician when a resident’s fluid intake exceeded the ordered 2500 mL/day restriction on four occasions. The resident was admitted with cor pulmonale, chronic respiratory failure, and chronic kidney disease, and the care plan addressed diuretic therapy. The physician order required staff to add up the prior day’s intake and update the MD if the fluid restriction was exceeded, but record review showed intake totals of 2700 mL, 3140 mL, 2800 mL, and 2600 mL on separate dates without documentation that the provider was notified. The DON stated there was no supporting documentation that the provider had been informed and that nursing was expected to follow the physician order. The facility also did not provide speech therapy services in accordance with the resident’s needs and prior recommendations for a resident with a history of cerebral infarction, dysphagia, aphasia, and moderate cognitive impairment. The resident had a BIMS score of 9/15 and had lost 10% of body weight since admission. The rehabilitation facility’s discharge recommendations included continued speech therapy at the LTC facility using dentures in place to address swallowing and speech deficits, but the facility’s speech therapy evaluations and treatment notes did not reference use of dentures. The resident was observed with pureed meals untouched and without dentures in place, and the speech therapist confirmed therapy sessions were conducted without dentures and that no follow-up was done to locate them, despite the resident stating the dentures were in the bedside stand. The facility also omitted hospital discharge orders when a resident was readmitted after a surgical procedure on the left thigh. The hospital discharge summary included a treatment for a laceration to the 5th toe on the left foot and a follow-up podiatry appointment related to fractures of the 4th and 5th left toes, but no treatment orders or care plan entries were found for the left foot laceration. Admission and weekly skin assessments did not identify a left foot impairment, provider notes did not mention the laceration, and staff interviewed were unsure about any left foot wound or treatment. The DON acknowledged that the treatment orders had been omitted and that the follow-up appointment had not been scheduled.
Omitted Left Foot Treatment and Missed Podiatry Follow-Up
Penalty
Summary
Proper foot care was not provided for one resident who had been readmitted after a surgical procedure on the left thigh requiring a wound vac. The hospital discharge summary dated 05/12/26 indicated the resident also had a laceration to the 5th toe on the left foot with a treatment to be completed by nursing, and that a follow-up appointment with podiatry was needed because of fractures of the 4th and 5th left toes. The resident’s orders and care plan contained no treatment orders or care plan related to the left foot laceration, and the After Visit Summary listed only radiology and orthopedic surgery appointments related to the left thigh fracture/fixation. During the survey, staff were unable to confirm the left foot treatment. A CNA stated she was not sure whether the resident had a wound or bandage on the left foot, and an LPN stated she was not sure about a treatment or wound to the left foot. When the foot was observed, a darkened area was present on the inner aspect of the 5th left toe, bruising was present on the 4th and 5th toes, and there was no treatment or bandage in place. The DON acknowledged the treatment orders had been omitted and the podiatry appointment had not been scheduled. The NHA stated the facility did not have a podiatry policy because it did not have direct facility podiatry services.
Improper catheter bag placement and lack of staff intervention
Penalty
Summary
The facility did not ensure appropriate catheter care and services to prevent urinary tract infections to the extent possible for 3 of 7 residents reviewed with indwelling catheters. Facility policy stated that residents with indwelling catheters should receive appropriate catheter care and that the drainage bag should be located below the level of the bladder to discourage backflow of urine. R1 had a Foley catheter related to BPH, obstructive and reflux uropathy, and chronic kidney disease, and the care plan directed staff to position the catheter bag and tubing below the bladder at all times. On observation, R1’s catheter bag was found in the seat of the wheelchair beside R1, and the CNA clipped the bag to the sheet in the wheelchair and pushed it back slightly before walking away; the bag remained uncovered and hanging out of the wheelchair armrest opening, rubbing against the right wheel. R6 had a suprapubic urinary catheter related to a history of UTIs, kidney stone, CKD, hydronephrosis, neurogenic bladder, and sepsis, and the care plan also directed staff to keep the bag and tubing below the bladder at all times. R6 was observed in the dining room with the catheter bag sitting in the wheelchair seat beside the resident while a CNA was present, but no intervention was made, and the bag remained in the seat during a later observation. R80 had a Foley catheter related to BPH and obstructive and reflux uropathy, with a care plan directing the bag and tubing below the bladder at all times. R80 was observed with the Foley drainage bag and cover bag entangled in the left front wheel of the wheelchair, and four staff members passed by without intervening. The DON stated that drainage bags should be placed below the bladder and that staff should move a bag to an appropriate location if noticed in the wrong place.
Nephrostomy Tubing Placed Above Kidney Level
Penalty
Summary
The facility did not ensure that a resident with bilateral nephrostomy tubes received care consistent with professional standards of practice. On 05/18/26, a surveyor observed the resident’s nephrostomy tubes placed up and over the back of the wheelchair and tucked into a pouch on the back of the chair above kidney level. The facility policy titled, Nephrostomy and Cystostomy Tube Care and Maintenance, states that residents with nephrostomy or cystostomy tubes will receive care consistent with professional standards of practice and that the drainage bag must be kept below the level of the kidneys at all times. Record review showed the resident was admitted with bilateral nephrostomy tubes related to a history of urinary tract infections, calculus of kidney, chronic kidney disease, hydronephrosis, neurogenic bladder, and a history of sepsis. The care plan included an intervention to position the catheter bag and tubing below the level of the bladder at all times. During interview, the DON stated nephrostomy drainage bags should be placed below the kidneys so urine flows down, and agreed it was not standard of practice for the tubes to run up and over the back of a wheelchair into a pouch above kidney level. A CNA also stated the tubing should be beside the resident and not hung over the wheelchair back.
Multiple Significant Medication Errors and Transcription Failures
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, despite a policy requiring accurate, safe, and timely medication administration. The policy directs staff to verify medication labels against the medication sheet for accuracy of drug, frequency, duration, strength, and route, and to check physician orders if there is any discrepancy. In multiple instances, staff did not follow these procedures, resulting in residents receiving wrong medications, wrong doses, wrong dosage forms, and discontinued medications that had not been removed from circulation. One cognitively intact resident with orthostatic hypotension and neurocognitive disorder with Lewy bodies was given another resident’s medications after an RN left a medication cart unattended between two rooms and then returned and handed the wrong medications to the resident. The medications included Oxycontin ER 20 mg and Amlodipine 5 mg, and the resident subsequently required Narcan and hospitalization, with hospital records later documenting marked orthostatic blood pressure changes requiring IV electrolytes and hydration. Another resident admitted with multiple rib fractures had an order for Oxycodone 5 mg every 6 hours for pain that was discontinued and changed to Hydrocodone 5-325 mg; however, the discontinued Oxycodone was not removed from circulation, and the resident received the wrong opioid medication on a later date. A resident on hospice care with chronic obstructive pulmonary disease, chronic pancreatitis, and generalized anxiety disorder was prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, but the medication was dispensed and administered in pill form instead of liquid on multiple dates. The Lorazepam was later discontinued but not removed from circulation, resulting in an additional dose being administered after discontinuation. Pharmacy review identified that another resident’s Tacrolimus dose was incorrectly transcribed in the medical record as 5 mg, two tablets twice daily instead of the ordered 0.5 mg, two tablets twice daily, and the resident received the wrong dose at morning administration. In separate incidents, one resident received another resident’s 40 mg Atorvastatin tablet, and another resident took another resident’s medications (gabapentin, clonidine, and Vitamin D) after medication cups were set at the bedside for two residents with the same initials, and one resident ingested the medications without checking the cup.
Failure to Timely Report Medication Error and Potential Neglect
Penalty
Summary
The deficiency involves the facility’s failure to timely report an incident of potential neglect to the state survey agency after a resident received the wrong medications, required Narcan, and was hospitalized. The facility’s abuse prevention policy defines possible neglect as the failure to provide goods or services necessary to avoid physical harm, pain, mental anguish, or emotional distress, or that could reasonably be expected to cause pain, injury, or death. The resident involved was admitted with orthostatic hypotension and a neurocognitive disorder with Lewy bodies, and had a BIMS score of 14/15, indicating intact cognition, with an activated power of attorney for health care. On the date of the incident, a licensed nurse administered medications intended for another resident, including Oxycontin ER 20 mg and Amlodipine 5 mg, to this resident. The physician was contacted immediately, Narcan was ordered and administered, and the resident was sent to the emergency department for observation of the medication error. In the hospital, the resident was found to be markedly orthostatic and received IV electrolytes and hydration, and was later transferred to another hospital when blood pressure began trending low, before eventually returning to the facility. During an interview with the surveyor, the DON stated the incident was not reported to the state agency because it was the nurse’s first medication error and there were no noted signs or symptom effects of receiving the wrong medication, and acknowledged that the 5-day investigation was not submitted within the required 5 days.
Failure to Investigate and Correct Medication Errors Leading to Multiple Significant Drug Administration Mistakes
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough and timely investigation and to implement corrective actions after an initial significant medication error, which allowed additional serious errors to occur. Facility policy on Medication Administration, revised 12/2025, requires accurate, safe, and timely administration of medications and verification of the medication label against the medication sheet, with physician orders checked if there is any discrepancy. Despite this, one resident admitted with multiple rib fractures was initially prescribed Oxycodone 5 mg every 6 hours for pain, which was discontinued and changed to Hydrocodone 5-325 mg every 6 hours on 06/26/25. On 07/02/25, this resident was administered the previously discontinued Oxycodone, which had not been removed from circulation. Following that event, the facility did not ensure that all licensed nurses were educated on medication administration requirements before their next shifts, and two further significant medication errors occurred. One cognitively intact resident with orthostatic hypotension and Lewy body neurocognitive disorder was given another resident’s medications, including Oxycontin ER 20 mg and Amlodipine 5 mg, and required Narcan and transfer to the ED, where the resident was found to be markedly orthostatic and required IV electrolytes and hydration before transfer to another hospital when blood pressure trended low. Another cognitively intact hospice resident with COPD, chronic pancreatitis, and generalized anxiety disorder had been prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, which was discontinued on 06/19/25 but not removed from circulation. The controlled substance log showed that this resident repeatedly received the wrong dosage form (tablet instead of liquid) on multiple dates and again received the wrong form and a discontinued medication on 07/06/25. These events occurred while nurse management were aware of the initial error but had not yet ensured all licensed staff were educated prior to subsequent shifts.
Failure to Properly Destroy and Discontinue Controlled Substances
Penalty
Summary
The facility failed to ensure proper destruction and disposition of controlled substances for two residents, contrary to its policy requiring unused, contaminated, or expired prescription drugs to be disposed of in accordance with state laws and with a witness to the destruction. For one resident, documentation showed an order for Pregabalin (Lyrica) 50 mg capsules twice daily that was later discontinued and changed to Pregabalin (Lyrica) 75 mg twice daily. The narcotic sheet for the 50 mg dose had an "X" across the sheet with a notation "Destroyed RN" and only one nurse’s signature. During interview, the DON stated that controlled substances should be discarded right away once it is known the resident will not be using them or when the provider discontinues the order, and acknowledged that the 50 mg Pregabalin should have been destroyed immediately and with two licensed staff, but was not. For another resident, Lorazepam oral concentrate 0.25 ml every four hours as needed for terminal anxiety was prescribed, but the facility’s controlled substance log initiated for this resident was labeled for Lorazepam 0.5 mg tablets. The log showed documentation that the resident continued to receive Lorazepam after the medication had been discontinued. In interviews, the DON and ADON acknowledged awareness of medication errors related to this situation. A registered nurse described the usual process for controlled substance destruction as using a drug buster in the medication storage room with two nurses signing off and verifying destruction, which contrasted with the documented practice in these cases.
Improper Labeling and Administration of Controlled Medications
Penalty
Summary
The facility failed to ensure medications were properly labeled, stored, and administered according to physician orders and facility policy for two residents. One resident with chronic obstructive pulmonary disease, chronic pancreatitis, and generalized anxiety disorder was admitted on 03/21/25 and placed on hospice care on 06/02/25. On that date, the resident was prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, but the medication was dispensed and administered in pill form instead of the ordered liquid concentrate. The controlled substance log initiated on 06/02/25 was labeled for Lorazepam 0.5 mg tablets, and documentation showed the resident received the wrong dosage form on multiple dates (06/04/25, 06/05/25, 06/06/25, 06/09/25, and 06/10/25). Additionally, the Lorazepam was discontinued on 06/19/25 but was not removed from circulation, and the resident received an additional dose without a physician’s order on 07/06/25. In a separate incident, a surveyor observed an RN at the medication cart and asked about narcotic administration. The RN presented the narcotic box, where the surveyor observed a morphine bottle with no label identifying the resident, the correct dose, or other required information, only a handwritten “#36” in permanent marker. When questioned, the RN had to search through narcotic records to determine that the bottle belonged to another resident and confirmed that the morphine oral concentration bottle was not properly labeled with the resident’s name, date of birth, pharmacy dispense date, or other identifying information. The RN acknowledged that this morphine had been administered 13 times without proper labeling and stated they had not realized the resident’s name was missing from the bottle. The DON later stated that liquid medications, especially morphine, were expected to be correctly labeled and that unlabeled morphine should not be administered.
Inaccurate PBJ Staffing Data Submission Resulting in Underreported Weekend Staffing
Penalty
Summary
The facility failed to ensure accurate reporting of direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) through the Payroll Based Journal (PBJ) system. Despite facility staff, including the DON and HR, stating that weekend staffing levels were consistent with weekday staffing and that call-ins did not differ between weekends and weekdays, the PBJ data submitted for multiple fiscal quarters indicated excessively low weekend staffing. Upon review, it was discovered that the process used by Corporate HR to pull and enter staffing data into the PBJ system was flawed. Specifically, if a staff member left employment before the data was pulled, their name and corresponding hours worked were deleted from the report, resulting in underreporting of actual hours worked. This underreporting led to inaccurate PBJ submissions, which triggered the facility to be flagged for low weekend staffing. The deficiency was identified through interviews with facility leadership and review of submitted PBJ data, schedules, and staff postings, which confirmed that multiple staff hours worked on weekends were not reported. This issue had the potential to affect all 71 residents residing in the facility, as the reported staffing levels did not accurately reflect the care provided.
Failure to Ensure Call Light Accessibility for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when a resident with monoplegia of the upper limb and COPD was not provided reasonable accommodation for their needs, specifically regarding access to their call light. The resident's care plan required that the call light be kept within reach due to their risk for falls and limited mobility. However, during an observation, the resident was found sitting in a wheelchair with the call light wrapped around the far-left bedside rail, out of reach. The resident was heard yelling for help and reported that staff often forgot to place the call light within reach after transfers from bed to wheelchair. The resident's most recent assessment indicated intact cognition and a need for partial to moderate assistance with mobility. The facility's fall management policy required adequate supervision and assistive devices to minimize fall risk. Despite this, staff failed to ensure the call light was accessible, as confirmed by both the resident and the DON, who acknowledged staff awareness of the resident's limitations and the importance of call light accessibility.
Failure to Follow Wound Care Orders and Infection Control During Pressure Injury Treatment
Penalty
Summary
A resident with multiple complex medical conditions, including sepsis, end stage renal disease, diabetes mellitus type 2, peripheral vascular disease, and chronic venous insufficiency, was admitted to the facility with several pressure injuries (PIs) and diabetic foot ulcers. The resident was dependent on staff for most activities of daily living and was identified as being at risk for pressure injuries. Physician orders specified a detailed wound care regimen, including cleansing, application of skin prep, Santyl ointment, calcium alginate, and zinc oxide to specific areas, to be performed daily and as needed. During a surveyor's observation, a registered nurse failed to follow proper infection control protocols and did not adhere to the physician's wound care orders. The nurse entered the resident's room without performing hand hygiene, donned gloves, and proceeded with wound care without changing gloves or sanitizing hands between steps. The nurse also omitted key steps in the wound care process, such as applying skin prep and Santyl ointment before the calcium alginate, as ordered. These actions were confirmed by the Assistant Director of Nursing, who acknowledged that hand hygiene and adherence to wound care orders were not followed during the observed care.
Failure to Prevent Accidents and Inadequate Supervision for Residents at Risk
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident with a history of cerebral infarction, severe cognitive deficit, generalized weakness, and osteoporosis was assessed as high risk for falls and required dependent assistance with toileting. Despite care plan interventions specifying that staff should remain with the resident while in the bathroom, the resident was left unsupervised for approximately 20 minutes, resulting in an unwitnessed fall. The resident was not observed to use the call light, and staff did not return to check on the resident during this period, contrary to the care plan and facility expectations. Another resident, who is cognitively intact but dependent on staff for toileting hygiene, lower body dressing, and transfers, was not properly assessed for independent vaping or smoking. Although the facility's policy requires an evaluation for all residents who use tobacco products or e-cigarettes, the resident was listed as able to smoke independently without a completed assessment or a care plan addressing vaping or smoking. The resident reported being able to go outside to vape, but the facility had not documented this in the care plan or completed the required assessment at the time of the survey. These deficiencies were identified through observation, interviews, and record reviews, which revealed lapses in following established policies and care plan interventions. The facility did not ensure that residents at risk for falls or those using tobacco products were adequately supervised or assessed, leading to preventable incidents and a lack of appropriate care planning.
Failure to Provide Ongoing Assessment and Monitoring for Dialysis Resident
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for a resident who required dialysis services. According to the facility's own policy, staff are required to assess the resident's condition and monitor for complications before and after dialysis treatments, including checking vital signs, weight, and the status of the dialysis access site. However, review of the resident's medical record revealed that there was no documentation of comprehensive assessments, such as vital signs, weight, or inspection of the dialysis port site, either before or after the resident returned from dialysis. The medication and treatment administration records only showed weekly vital signs and weights, with no specific documentation related to pre- and post-dialysis care. Interviews with the resident and the Director of Nursing confirmed that staff did not consistently perform or document assessments upon the resident's return from dialysis. The resident reported that staff sometimes checked vital signs after dialysis, but not always immediately upon return. The DON acknowledged that staff did not document assessments after dialysis and that there was no established process for assessing the dialysis port site upon return, as some dialysis facilities preferred the bandage not be removed. The lack of ongoing assessment and monitoring was not consistent with the facility's policy or the resident's care plan.
Infection Control Lapses in Hand Hygiene, PPE Use, and Catheter Bag Management
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in hand hygiene, use of personal protective equipment (PPE), and proper handling of medical devices. During wound care for a resident with multiple pressure injuries and diabetic foot ulcers, a registered nurse did not perform hand hygiene at required intervals, failed to use a gown as part of enhanced barrier precautions (EBP), and used personal supplies without proper disinfection. The nurse also placed contaminated items back into personal storage and did not sanitize equipment after use, contrary to facility policy and infection control standards. In another instance, a certified nursing assistant (CNA) did not perform hand hygiene after removing gloves during incontinence care for a resident, instead proceeding to handle clean items and assist with dressing without sanitizing hands. The CNA acknowledged the lapse when questioned and confirmed that hand hygiene should have been performed between glove changes, as required by facility policy. Additionally, a resident with an indwelling urinary catheter was repeatedly observed with the catheter bag lying on the floor, despite facility policy stating that drainage bags should not touch the floor. Staff were seen handling the bag and placing it back on the floor, and the resident reported that the bag was always on the floor. The care plan for this resident did not address proper placement of the urinary collection bag, and staff interviews confirmed the expectation that the bag should be kept off the floor.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to its policies regarding the storage, labeling, and dating of food items, which are essential to prevent foodborne illnesses. During a survey, multiple unlabeled and potentially expired food items were found in the facility's walk-in refrigerator and resident kitchenette. These included containers of Italian dressing, relish, whipping cream, milk, sour cream, and various dressings, some of which lacked open date labels or had expired manufacturer's dates. The Dietary Manager (DM) and Dietary staff admitted to not labeling items with open dates and acknowledged the presence of expired items. The surveyor observed that the facility's policy required all refrigerated and prepared food to be covered, labeled, and dated with a use-by date. However, this policy was not consistently followed, as evidenced by the presence of unlabeled and expired food items. The DM indicated that it was the responsibility of the kitchen staff to monitor the resident fridge, but this was not being done effectively. The DM also mentioned that nursing staff were expected to monitor the fridge, but this was not occurring, leading to expired food items being stored in the resident refrigerator. The Nursing Home Administrator (NHA) was unaware of any foodborne illnesses among staff and residents, but acknowledged the deficiency after being informed by the DM. The DM admitted to the NHA that items in the kitchen were not labeled with open dates and that expired items were found in the kitchen area. This lack of adherence to food safety protocols posed a risk of foodborne illness to the residents, although no illnesses were reported at the time of the survey.
Failure to Convey Deceased Resident's Trust Funds
Penalty
Summary
The facility failed to ensure the timely conveyance of a deceased resident's trust funds to the appropriate party. Specifically, the facility did not return the trust funds of a resident, identified as R1, to the Power of Attorney (POA) or family within 30 days of the resident's death. The facility's policy on Resident Trust Accounts mandates that upon a resident's death, the facility must promptly convey the resident's funds and provide a final accounting to the individual administering the resident's estate. However, a review of R1's account history revealed a positive balance of $180.11, with no documentation of funds being conveyed to the POA. During the survey, a family member of R1, identified as FM C, reported that the facility refused to refund the trust account balance, citing an outstanding balance of $5,000 owed by FM C. The Nursing Home Administrator (NHA) expressed uncertainty about the remaining balance, while the Accounts Receivable Specialist claimed that all trust accounts are typically conveyed within 30 days of discharge or death. Despite this assertion, the funds had not been returned, indicating a lapse in the facility's adherence to its policy and regulatory requirements.
Failure to Report Falls to Physician
Penalty
Summary
The facility failed to immediately report falls to the physician for two residents, leading to a deficiency in communication and care. The first resident, diagnosed with Alzheimer's disease and other conditions, experienced a fall on 09/09/24. Despite being found on the floor and examined for injuries, there was no documentation that the physician or family members were notified of the incident. An investigation later revealed that the nurse on duty did not inform the necessary parties, resulting in disciplinary action against the nurse. The second resident, with diagnoses including dementia and repeated falls, had two unwitnessed falls on 10/09/24 and 10/24/24. There was no documentation of physician notification for either incident. The Director of Nursing (DON) was unaware of the falls until observing the resident with facial bruising. The lack of documentation and communication with the physician regarding the resident's injuries and falls highlights a significant lapse in following the facility's change in condition policy.
Failure to Conduct Proper Assessments After Falls
Penalty
Summary
The facility failed to provide care and treatment according to professional standards of practice for two residents following falls. Resident 1, who had severe cognitive impairment and was at risk for falls, experienced a fall on 09/09/24. The resident was found on the floor tangled in bedding, but the nurse did not perform a thorough assessment, including vital signs, neurological checks, or a head-to-toe examination. The fall was not reported to hospice services or the family until the following day when the resident showed signs of pain and bruising, indicating a possible injury. Resident 2, diagnosed with dementia and at risk for falls, had an unwitnessed fall and another incident where they slid out of a wheelchair. Despite these events, there was no documentation of a comprehensive assessment, including vital signs or neurological checks, in the resident's records. The Director of Nursing was unaware of the falls until observing the resident with facial bruising, suggesting a lack of communication and documentation by the nursing staff. The facility's failure to conduct proper assessments and communicate falls to relevant parties resulted in deficiencies in maintaining the residents' highest practicable level of physical well-being. The lack of documentation and communication highlights a significant gap in the facility's fall management protocol, as outlined in their policy, which requires thorough assessments and timely reporting of falls to physicians and family members.
Failure to Implement Post-Fall Interventions
Penalty
Summary
The facility failed to implement new care planned fall interventions for three residents who were at risk for falls. Resident 1, diagnosed with Alzheimer's disease and other conditions, experienced a fall on 09/09/24. Despite a discussion on 09/11/24 to add a fall mat as a new intervention, this was not added to the care plan, and no other interventions were updated following the fall. Resident 2, with diagnoses including dementia and repeated falls, had two falls on 10/09/24 and 10/24/24. The facility did not implement any new interventions after these incidents, despite the resident's care plan being in place since 04/22/24. The care plan included various interventions, but none were updated or added following the falls. Resident 3, who had a history of falling and other medical conditions, fell on 10/21/24. The care plan, initiated in 2018, was not updated with new interventions after the fall. The Director of Nursing acknowledged that no new interventions were implemented for any of the residents after their falls, citing that staff sometimes miss implementing new interventions.
Improper Hand Hygiene and Hair Net Use in Food Service
Penalty
Summary
The facility did not ensure proper hand hygiene and use of hair nets in accordance with professional standards for food service safety. During an initial walkthrough of the kitchen, a Certified Nursing Assistant (CNA) was observed entering the kitchen without wearing a hair net, despite a sign indicating that hair nets were required. The CNA indicated they were just grabbing coffee, but their uncovered hair could easily fall into the coffee cup, which was located near the cooking and plating areas of the kitchen. Additionally, during the point of service plating before lunch, a Dietary Cook (DC) was observed using gloves to place bread on residents' plates. However, the DC touched their glasses and stove controls without changing gloves or using hand hygiene before continuing to handle the bread. The Dietary Manager (DM) confirmed that they would expect anyone entering the kitchen to wear a hair net and that staff should use tongs or change gloves and wash hands if unclean items are touched during the serving process.
Failure to Schedule Follow-Up Oncology Appointment
Penalty
Summary
The facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to follow physician orders to schedule a follow-up oncology appointment within 2-4 days after admission for a resident diagnosed with a lesion on the left ninth rib, which could represent metastatic disease. The hospital discharge summary clearly indicated the need for this follow-up, but the facility did not act on these orders in a timely manner. The facility's admission checklist required multiple checks and signatures to ensure all orders were followed, but this process was not effectively executed. The Social Services Assistant, responsible for scheduling appointments, did not receive the necessary information to schedule the oncology follow-up. Interviews with staff, including the DON and RN, revealed that the facility's procedure for scheduling appointments was not followed, and there was confusion about the responsibility for ensuring the appointment was made. The resident confirmed awareness of the oncology referral but was unsure if the appointment had been scheduled. The DON and other staff members acknowledged the oversight and indicated that the facility was waiting for insurance authorization, which had not been communicated effectively. There was no documentation of attempts to schedule the appointment or communicate with other providers until the surveyor's review, indicating a lapse in the facility's protocol and communication processes.
Failure to Supervise Resident During Use of Oscillating Percussion Vest
Penalty
Summary
The facility did not evaluate for hazards or risks related to the use of an oscillating percussion vest for a resident with quadriplegia and a high risk for aspiration. The resident, who has a history of aspiration pneumonia and other severe medical conditions, was observed alone in his room wearing the vest without supervision. The care plan did not address whether the resident was safe to be left alone with the vest or how supervision would be provided during the treatment sessions. Staff interviews revealed that the resident was unable to use a call light to ask for assistance, and there was no clear protocol for ensuring the resident's safety during the vest treatment. The resident's physician orders included the use of the Afflo Respiratory Vest twice daily while sitting up in a wheelchair, with specific instructions to stop tube feeding during the session and check the resident's mouth and lung sounds afterward. However, observations and staff interviews indicated that these orders were not consistently followed. For instance, the surveyor did not observe nursing staff checking the resident's lung sounds after a vest session, and the resident had a large amount of mucus in his mouth that required oral care. The Director of Nursing (DON) confirmed that the resident's care plan did not initially include the use of the chest vest and that an assessment to determine if the resident was safe to wear the vest unsupervised had not been conducted. Despite the manufacturer's instructions indicating that disabled persons should not use the vest without supervision, the facility did not have a clear protocol for supervising the resident during vest treatments. Staff reported that they usually kept the resident by the nurse's station or left his door open for observation, but this was not documented in the care plan or consistently practiced.
Improper Verification of G-Tube Placement During Medication Administration
Penalty
Summary
The facility did not ensure that residents who are medicated by enteral means received the appropriate treatment to prevent complications during medication administration through a Gastric tube (G-tube). This was observed with one resident who received medication without ensuring the G-tube was appropriately placed prior to medication administration. The resident, who had diagnoses of epilepsy, cerebral palsy, and functional intestinal disorder, was observed receiving valproic acid via G-tube without proper verification of tube placement according to current standards of practice. The Licensed Practical Nurse (LPN) administering the medication used an outdated method of injecting air into the G-tube and listening for noise to check for proper placement. This method is no longer the standard of practice, as confirmed by the surveyor and the Director of Nursing (DON). The facility's policy, last revised in March 2020, still included this outdated practice, leading to the deficiency observed during the survey.
Infection Control Deficiencies
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Staff failed to perform proper hand hygiene during medication administration with a resident who had a severe cognitive impact. Specifically, a registered nurse did not perform hand hygiene before and after administering medications to the resident and proceeded to check another resident's blood sugar without proper hand hygiene initially. This was observed by a surveyor and confirmed by the Director of Nursing, who acknowledged that the nurse should have performed hand hygiene between residents. Additionally, the facility prematurely removed droplet precautions for a resident who tested positive for COVID-19. The resident was supposed to remain on droplet precautions for ten days following the onset of symptoms, but staff miscounted the isolation days, leading to the removal of precautions one day early. This error was identified when the surveyor observed the resident on contact precautions instead of droplet precautions. The Assistant Director of Nursing confirmed that the miscalculation occurred because staff did not count the first day of isolation as day zero, resulting in the premature removal of droplet precautions.
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Illustrative
What surveyors actually found near you
We read the 72 citations issued within 25 miles in the last 12 months — including the 1 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 Chetek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Barron Care And Rehabilitation | 11.4 mi | ★★★★★ | 19 | 0 |
| Heritage Lakeside | 14.2 mi | ★★★★★ | 15 | 1 |
| Dove Healthcare - Rice Lake | 14.5 mi | ★★★★★ | 15 | 0 |
| Dove Healthcare - Bloomer | 16.4 mi | ★★★★★ | 1 | 0 |
| Meadowbrook At Bloomer | 16.9 mi | ★★★★★ | 8 | 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.