Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medical Suites At Oak Creek (the) during CMS and state inspections, most recent first.
A resident with heart failure, chronic respiratory failure, gait and mobility issues, and need for personal care assistance had MDS findings showing dependence or substantial assistance needs for eating, hygiene, dressing, bathing, toileting, and transfers. Surveyors found no ADL care plan and no CNA Kardex information to guide staff on the resident's required assistance, and the CNA, UM, and DON stated that this information should be available in those documents.
A resident who was dependent on staff for bathing did not receive the required showering services or weekly bathing documented by the facility. The resident said no shower had been provided since admission and only wipes were used, while the care plan, CNA schedule, shower sheets, EHR task records, and progress notes showed no documented shower and only a few bed baths. Staff confirmed the resident had a set shower day and that showers should be documented, but no completed shower record was found for the resident.
A resident with heart failure, chronic respiratory failure, and mobility issues was admitted with intact cognition and staff assist for meals, but the nutritional assessment and care plan did not address missing upper teeth and multiple lower teeth or the resident’s chewing difficulty. The resident told the surveyor that facility food was hard to chew without dentures, and staff interviews showed the issue was not incorporated into diet planning. The resident also had an MD order for weekly weights, but the record showed only admission and later weights, not the ordered weekly monitoring.
Failure to assess and treat changes in condition, wounds, and ordered care. The facility did not promptly respond to lab abnormalities, wound decline, swallowing changes, or other acute status changes for multiple residents. One resident with dementia, DM, AKI, dehydration, and pressure injuries had delayed lab review, no new orders for progressive changes, worsening coccyx wounds with possible osteomyelitis, and a diet change without proper assessment or order. Other residents had missed consults, uncompleted ordered labs and weights, and unassessed injuries including fractures and skin alterations.
Failure to Assess, Treat, and Prevent Pressure Injuries: A resident at risk for skin breakdown developed two facility-acquired unstageable coccyx wounds after a decline in mobility and incontinence, but the wounds were not promptly comprehensively assessed, the care plan was not updated, and an x-ray later showed possible osteomyelitis that was not further evaluated. Another resident developed an avoidable elbow PI without timely pressure-relieving interventions, and a third resident developed a facility-acquired stage 3 hand PI related to embedded fingernails with no timely care plan update or full assessment.
The facility failed to provide adequate supervision and accident prevention for residents with significant cognitive and mobility impairments. A resident with prior brain injury and hemiplegia had an unwitnessed fall, then another fall that resulted in an eye laceration and TBI requiring ICU admission, without an immediate fall investigation or care plan revision. Another dependent resident with severe contractures and a history of falls was cared for alone in bed, rolled out of bed, and later was diagnosed with bilateral tibia and fibula fractures. A third resident had repeated unwitnessed falls, with no root cause identified and neuro checks not completed after the second fall.
Insufficient nursing and CNA staffing was identified when the facility’s staffing patterns showed repeated shortages across PM and night shifts, including a missed PM nurse shift due to a no call/no show and multiple CNA shortages. The Scheduler stated staffing was based on census and acuity, but could not say who passed meds on the unit when the nurse did not report for the PM shift.
Infection surveillance records were missing for several months, and the facility did not have a documented system to track infections and communicable diseases as required by policy. In addition, an LPN used a shared glucometer for a resident with type 2 DM and cleaned it with alcohol wipe pads instead of the facility’s required disinfection process between residents.
The facility did not ensure that 5 of 5 CNAs reviewed received required communication training. The CNAs had all worked at the facility for more than 1 year, but the facility could not provide evidence of the training. The HR Director said HR handled onboarding only and did not track annual training, while the NHA and DOO confirmed there was no evidence of the training and no organized system for employee training records.
The facility did not provide evidence that 5 of 5 reviewed CNAs received required resident rights training. The CNAs had been employed for more than 1 year, but the facility could not produce training records. HR stated onboarding was handled by HR, annual training was not tracked there, and there was no Nurse Educator or Staff Development Coordinator. The NHA and DOP confirmed there was no organized system for employee training records.
Missing Required Abuse, Neglect, and Exploitation Training: The facility could not provide evidence that 5 CNAs with more than 1 year of service had completed required training on abuse, neglect, and exploitation. The HR Director said HR handled onboarding but not annual training, while the NHA and DOP confirmed there was no evidence of the training and no Staff Development Coordinator or designee maintaining a training schedule or documentation system.
Required QAPI training was not documented for 5 of 5 CNAs reviewed, all of whom had worked at the facility for more than 1 year. The facility could not produce evidence of the training, and the HR Director, NHA, and DOP confirmed there was no organized system or designated Staff Development Coordinator/Nurse Educator tracking annual training records.
Missing Infection Control Training Documentation for CNAs: The facility did not provide evidence that 5 CNAs received required infection prevention and control training, even though each had worked at the facility for more than 1 year. The HR Director stated HR handled onboarding only and did not track annual training, and the NHA and DOP confirmed there was no evidence of the training, no organized training records, and no Staff Development Coordinator or designee maintaining training documentation.
Missing Compliance and Ethics Training for Direct Care Staff: The facility could not provide evidence that 5 CNAs had received required compliance and ethics training, even though each had worked there for more than 1 year. The facility's policy required this training and documentation in personnel files, but the HR Director, NHA, and Director of Operations confirmed there was no organized training record system, no Nurse Educator or Staff Development Coordinator, and no evidence the training had been provided.
Missing Annual CNA Training Documentation: The facility did not provide evidence that 5 of 5 CNAs completed the required 12 hours of annual training. The selected CNAs had worked at the facility for more than a year, but training records were not organized, HR handled only onboarding, and there was no Nurse Educator or Staff Development Coordinator maintaining the annual training schedule or documentation.
Failure to Provide Required Behavioral Health Training: The facility did not provide evidence that 5 CNAs who had worked there for more than 1 year received required behavioral health training. Review of records and staff interviews showed the facility had no organized system for tracking annual training, no Staff Development Coordinator or Nurse Educator, and training records were kept in boxes from the previous DON.
A resident with hydrocephalus, severe contractures, and moderate cognitive impairment rolled out of bed while a CNA was providing cares alone, despite a care plan requiring 2 staff for interactions. The resident later developed ankle deformity, extensive BLE bruising, swelling, and fractures that did not correlate with the reported fall. The facility’s abuse investigation was incomplete because it relied on limited staff statements and did not include resident interviews or a thorough review of the allegation.
A review of MARs and TARs showed that 13 of 13 sampled residents on the Sparkle unit missed multiple ordered meds during the night shift, including antihypertensives, insulin, anticoagulants, anticonvulsants, psychotropics, and other routine medications. Staff interviews indicated there was no nurse covering the back part of the unit until late in the shift, the LPN found the meds already overdue, and the physician was not notified.
The facility failed to notify the MD and/or resident representatives of significant changes for three residents. One resident had a 20 lb. weight loss with missed weights and no documented MD notification. Another resident had a fall with injury, but the community RN case manager was not notified within the expected timeframe. A third resident with an activated HCPOA had wound decline, abnormal imaging, treatment changes, and a diet downgrade, but there was no documentation that the HCPOA was informed.
A resident voiced a grievance about referrals to 2 SNFs, but the facility did not document a thorough investigation, the results of the referrals, or communication of the findings to the resident. Record review showed notes that 2 referrals were made and later that 1 SNF had no beds and the other was pending, but there was no documentation of who was contacted, what paperwork was sent, or the outcome of the second referral. The resident stated they had not received proof of the referrals or been told the outcome.
A resident with severe cognitive impairment, bladder incontinence, mobility decline, pressure injuries, wounds, and multiple chronic conditions had an annual MDS that triggered several CAAs, but the facility did not complete a resident-specific comprehensive analysis to support the care plan. Multiple CAAs contained blank sections or generic rationales, including cognitive loss, urinary incontinence, behavioral symptoms, falls, nutrition, dental care, pressure injury, and psychotropic drug use, and the bladder continence change was not addressed in the care plan.
Care Plans Not Updated After Changes in Condition: The facility did not ensure interdisciplinary review and revision of care plans for two residents after changes in status. One resident with severe neuro deficits and dependence for all ADLs had falls and the care plan was not updated with person-centered fall interventions. Another resident with severe cognitive impairment, worsening mobility and bladder incontinence, and an unstageable coccyx pressure injury had care plans that were not revised to reflect increased bed mobility assistance, individualized repositioning, or more specific incontinence interventions.
A resident with Parkinson’s disease, dementia, and severe bilateral hand contractures was fully dependent on staff for ADLs, but nail care and hand hygiene were inconsistently documented and not maintained. Weekly shower records showed multiple missed or blank entries for fingernail care, and OT and nursing documented that a fingernail had become embedded in the resident’s palm, causing a wound and pain. The care plan still listed the family as responsible for nail care, despite the resident’s condition and the embedded nail event.
A resident with a Foley catheter was observed with urine in the drainage bag, but the chart had no current MD order, indication for use, or care plan for the catheter. The resident said they had had the catheter for over a year and had never seen a urologist, while the CNS confirmed there were no catheter orders or documented catheter care/services after readmission.
Failure to Obtain Admission Weight and Follow Ordered Weight Monitoring: A resident with DM2, dementia, anxiety, depression, muscle weakness, cognitive communication deficit, and COPD was admitted with an order for an admission weight and weekly weights, but the facility did not obtain a facility admission weight and only documented one later weight. The RD reviewed hospital discharge paperwork showing a higher weight, requested a re-weight, and noted an approximately 20 lb. loss when the resident was finally weighed. Staff could not show that the resident refused weighing, and the care plan was not revised after the weight discrepancy was identified.
A resident with an activated POAHC and multiple chronic conditions developed worsening pressure injuries, venous wounds, swallowing difficulty, and suspected osteomyelitis, with a NP documenting decline and hospice discussions. The record contained no Social Services documentation showing involvement in the resident’s clinical changes, hospice referral, discharge planning, or communication with the POAHC about end-of-life care, treatment options, or test results. Interview information also indicated the POAHC did not agree to hospice and was not aware of the wound infection or intake concerns.
A resident with HTN, dementia, stroke history, DM2, dysphagia, and CKD stage 4 missed an ordered amlodipine dose when the LPN could not find the medication card. The LPN called the pharmacy, but did not check contingency stock or notify the physician. The UM later stated the facility reviews missed meds the next day and acknowledged contingency should have been checked, but there was no usable medication list available.
Medication administration errors exceeded the allowed rate, with a 12% error rate found during observation. An LPN gave a resident enteric-coated aspirin instead of ordered chewable aspirin, and an RN gave another resident chewable aspirin instead of ordered EC aspirin plus senna instead of ordered senna-docusate. The orders and administered medications did not match for the affected residents.
Unlabeled insulin pens were found in an LPN's med cart on the Sparkle front unit. Surveyors observed three insulin pens in a drawer without resident names or dates showing when they were opened or expired. When asked how staff would know which resident the pens belonged to, the LPN stated staff don't know. The facility's policy required insulin pens to be labeled with the resident name and date information, but the pens were not labeled accordingly.
A resident with multiple chronic conditions, including dysphagia risk, had a diet change from mechanical soft with thin liquids to pureed with nectar thick liquids after staff noted pocketing food. The record lacked a physician or RD order and did not show a comprehensive swallowing assessment or speech therapy referral tied to the downgrade. Interviews confirmed the RD was unaware of the diet change, the DOR had no therapy assessment for swallowing, and the NP believed a verbal order had been given, but no documentation supported it.
A resident with ESRD on dialysis, type 2 DM, asthma, and chronic respiratory failure requested the flu vaccine, and the chart documented consent for flu and COVID vaccines. Surveyors found no record that the resident was offered, declined, or received the flu shot, and the DOO confirmed the resident wanted the flu vaccine but did not receive it.
Three residents did not receive timely or consistent care as required by physician orders and facility policy. One resident did not have weekly skin assessments or prompt treatment for a new skin impairment, another did not have daily weights or fluid intake consistently monitored despite fluid restriction orders, and a third experienced a delay in urinalysis processing due to labeling errors, resulting in delayed treatment for a UTI.
A resident with multiple risk factors for pressure injuries experienced a decline in health and began refusing dialysis, medications, and meals. Despite these changes, staff did not perform comprehensive skin assessments or update the care plan, and only a toe abrasion was monitored. When the resident was hospitalized, four pressure injuries were identified, and facility records showed no documentation of required weekly skin assessments or care plan revisions during the period of decline.
A resident with heart failure and fluid overload did not receive nine doses of a prescribed eye drop medication because the medication was unavailable and not reordered promptly. The resident, who was cognitively intact and did not refuse care, went several days without the medication, and no follow-up was done to obtain it during that time.
Two residents with recent fractures did not receive their prescribed pain medications due to delays in obtaining valid prescriptions and confusion over accessing the emergency medication supply. Both experienced severe, uncontrolled pain, with one requiring transfer to the ER for pain management. Staff interviews and documentation revealed breakdowns in communication, pharmacy coordination, and adherence to pain management protocols.
The facility failed to maintain proper food safety and sanitation, with milk stored at unsafe temperatures, dirty kitchen and pantry areas, and undated or unlabeled food items found in a pantry refrigerator. An LPN confirmed improper milk temperatures, and a Certified Medication Aide disposed of questionable food. The Food Service Director acknowledged lapses in cleaning schedules, and there was no documentation of required food holding temperatures during meal service.
Surveyors observed that two exterior trash bins near the kitchen, one for recycling and one for trash, were left with lids open and surrounded by debris, including gloves, a mask, and an empty plastic container. The trash bin was also overflowing with trash bags. The FSD acknowledged the issue, the RD did not check the area, and the Administrator stated there was no trash policy. This failure had the potential to affect all 116 residents.
The facility did not develop or implement effective QAPI activities to address repeated deficiencies in food palatability, garbage disposal, and infection control, resulting in ongoing noncompliance. Despite identifying these issues in prior surveys, there were no documented improvement plans or monitoring tools, and the facility did not follow its own QAPI policy.
Several cognitively intact residents reported that their meals were often cold or lukewarm, with complaints documented in resident council notes and confirmed by the RD. Observations showed that food temperatures dropped significantly between preparation and service, resulting in hot foods being served below the expected temperature and cold foods above the recommended range, contrary to facility policy.
Multiple residents experienced prolonged wait times for call light responses, with documented delays often exceeding 20 minutes and sometimes reaching up to 45 minutes. Residents with various medical conditions reported waiting for assistance, including during episodes of incontinence. Staff interviews and call light data confirmed that short staffing and lack of an effective alert system contributed to these delays, and residents expressed concerns about insufficient staff support.
A resident with multiple chronic conditions and moderate cognitive impairment was allowed to self-administer medications without a physician's order or care plan in place. An RN left the resident alone with medications during a medication pass, contrary to facility policy requiring direct observation. Both the RN and DON confirmed that the resident was not authorized for self-administration and that proper supervision was not provided.
Three residents requiring assistance with bathing did not receive scheduled baths or showers, as documented in their records and confirmed by staff and resident interviews. Issues with hot water availability led to missed or substituted bed baths, and some residents were not offered alternative bathing options. The DON was unable to confirm that scheduled bathing occurred and acknowledged the deficiency.
A resident with an abdominal hematoma and moderate cognitive impairment had CBCs performed every two weeks without a physician order being entered into the electronic medical record. Staff interviews revealed confusion over who was responsible for entering lab orders, and the facility lacked a policy on laboratory services.
A resident with severe cognitive impairment and a terminal prognosis did not have complete documentation of required hospice skilled nurse and aide visits, as specified in the hospice plan of care. Staff interviews revealed inconsistent understanding of visit frequency, and the DON confirmed that documentation was missing. The administrator was unable to provide the hospice contract during the survey.
Staff failed to use PPE when entering a contact isolation room for a resident with C. Diff and did not follow proper procedures during medication administration, with a nurse handling pills with bare hands. Additionally, infection control policies were not reviewed or updated annually as required.
A resident with intact cognition and a signed DNR form was incorrectly listed as Full Code in the EMR, with both the Profile tab and a physician's order indicating CPR should be provided. Despite the resident's clear wishes and a DNR bracelet, staff were unaware of the discrepancy, and the process for verifying code status orders was not consistently followed.
A resident who was cognitively intact and transferred to the hospital for GI bleeding did not receive a properly completed Bed Hold/Transfer Notice, and the ombudsman was not notified of the discharge. The required documentation was incomplete, lacking resident signature and transfer details, and there was no evidence that the resident or their representative received the notice. Staff interviews confirmed missing ombudsman notifications for multiple months due to staffing issues.
A resident with a history of depression and behavioral incidents, including threats and aggressive interactions with staff and family, did not have a care plan reflecting her behavioral health needs. Despite staff awareness of these behaviors, no formal interventions or individualized care plan were documented, resulting in a deficiency in comprehensive care planning.
A resident with multiple medical conditions, including advanced wounds and dysphagia, experienced a 19% weight loss in one month. Despite care plan updates noting the weight loss, no new interventions were implemented by the physician or RD, and the DON was unaware of the issue. The resident continued to receive the same supplements and feeding assistance, and the facility did not follow its policy to address significant weight changes.
A resident with COPD who required nebulizer treatments was found to have their nebulizer mask left uncovered on a bedside table, rather than stored in a plastic bag as required by facility policy. Staff confirmed that this did not follow infection control guidelines for respiratory equipment.
Missing ADL Care Plan and CNA Kardex Guidance
Penalty
Summary
The facility did not develop an Activities of Daily Living (ADL) comprehensive plan of care for one resident who was admitted with diagnoses including heart failure, local skin infection, chronic respiratory failure, abnormalities of gait and mobility, and need for assistance with personal care. The resident's admission MDS documented that the resident was cognitively intact and required staff assistance with set up and cleaning for eating and hygiene, was dependent on staff for dressing and toileting, required substantial/maximal assistance for showering/bathing, and was dependent on staff for transfers. Survey review of the resident's comprehensive care plan and CNA Kardex found no ADL care plan and no information on the CNA Kardex to guide staff on the resident's needed assistance with bathing/showering, bed mobility, dressing, eating, toileting, hygiene, or transfers. During interviews, a CNA stated that this information would be in the CNA Kardex, and the UM and DON stated that the CNA Kardex and care plan should contain it. The DON acknowledged the concern when informed that the resident did not have an ADL care plan or CNA Kardex information for ADLs.
Failure to Provide Scheduled Bathing and Document Showers
Penalty
Summary
The facility did not provide the necessary ADL bathing services for one dependent resident who was admitted with diagnoses including heart failure, local skin infection, chronic respiratory failure, gait and mobility abnormalities, and need for assistance with personal care. The resident’s admission MDS documented cognitive intactness, dependence on staff for dressing, toileting, and transfers, and substantial to maximal assistance needed for showering/bathing. The resident also stated that choosing between a tub bath, shower, bed bath, or sponge bath was very important. The facility policy titled Resident Showers stated residents would be provided showers as per request and within reasonable accommodation, or as per facility schedule protocols at least weekly. The resident’s MD order identified Wednesday as the shower day. However, the resident told the surveyor that no shower had been received since admission, that the resident had been asking for a shower, and that only wipes had been used for cleaning. The resident also stated that showers were relaxing and helped with sleep, and denied refusing showers. Surveyor review of the care plan, CNA kardex, shower binder, shower sheets, EHR bathing task documentation, and progress notes showed no documented shower for the resident since admission and no documented refusal. The EHR bathing task section showed only bed baths on a few dates, with gaps of 10 days and then 11 days without documented bathing. Staff interviews confirmed showers were scheduled by day and shift, documented on shower sheets and in the EHR, and that the resident’s shower day was Wednesday night shift, yet the resident was unaware of that schedule and no completed shower sheet for the resident was found.
Incomplete nutritional assessment and missed weekly weights
Penalty
Summary
The facility did not ensure that a resident received the necessary services for acceptable nutrition. The resident was admitted with diagnoses including heart failure, chronic respiratory failure, gait and mobility abnormalities, and need for assistance with personal care. The resident’s admission MDS documented cognitive intactness, need for staff assistance with set-up and cleaning for eating, and no swallowing complaints. However, the resident told the surveyor that the resident had lost dentures before admission, does not typically eat the facility food, and had difficulty chewing the facility’s hot apples because they were too hard and the resident had no teeth. The resident’s comprehensive nutritional assessment and care plan did not address the resident’s missing upper teeth and multiple lower teeth or document interventions related to chewing difficulty. The admission head-to-toe evaluation documented that the resident did not wear dentures, but facility staff did not document that the resident had previously had dentures that were no longer available. The nutritional note stated that the resident reported no chewing or swallowing concerns, and the care plan focused on obesity, heart failure, and cellulitis/edema, with interventions such as monitoring outside food and encouraging facility meals. Surveyor observation and staff interviews showed that the resident’s dentition issue had not been incorporated into the nutritional assessment or care planning, and staff did not document that a soft texture diet had been offered or that risks and benefits of the current diet had been discussed. The resident also had an MD order for weekly weights, but the facility did not follow the ordered schedule. The resident was weighed on admission and then again several weeks later, with no weekly weights documented as ordered. Staff interviews indicated that weights were expected on admission, weekly for four weeks, and then monthly, but the resident’s record did not show weekly monitoring during the ordered period. The surveyor informed facility leadership of the concerns related to the resident’s nutritional assessment and weights, and no additional information was provided.
Failure to Assess and Treat Changes in Condition, Wounds, and Ordered Care
Penalty
Summary
The facility failed to provide care and treatment according to orders, resident preferences, and professional standards for multiple residents, including failures to assess changes in condition, implement ordered labs and treatments, and communicate significant changes to appropriate personnel. For one resident with multiple chronic conditions including dementia, diabetes, AKI, dehydration, pressure injuries, and dysphagia, staff did not address declines in incontinence and mobility identified on the MDS, did not promptly review repeat lab results, and did not place new orders or monitoring when labs showed progressive changes in hydration, kidney function, protein levels, and later elevated glucose. The resident also developed pocketing of food and a diet downgrade was submitted without a documented assessment or order, and the dietitian was not notified of the wound and nutritional changes. The same resident developed worsening coccyx pressure injuries that were not comprehensively assessed when first identified, and treatment documentation showed delays and gaps. Imaging later indicated the coccyx wound could not rule out osteomyelitis, but no additional assessment, MRI order, culture, or treatment plan was documented. Nursing notes described increased pain, drainage, and the resident staying in bed due to coccyx wound pain, while the record showed no individualized revisions to the care plan to address the decline. The resident’s activated POAHC stated she was not informed of the full extent of the resident’s changes in condition during December and did not agree to hospice or end-of-life care, despite later documentation indicating a transition to comfort-focused care. The facility also failed to respond to acute changes for other residents. One resident with a Foley catheter had a urology consult ordered, but there was no documentation that it was implemented. Another resident admitted for rehabilitation and receiving diuretics had an ordered lab draw, daily weights, and fluid restriction that were not carried out as ordered; a previously drawn potassium result of 2.9 was not acted on, and the resident was later transferred emergently with potassium 2.5 and required hospitalization. Additional cited concerns included a resident who rolled out of bed while being cared for alone, then later had crackling, deformity, bruising, and ultimately bilateral tibia and fibula fractures diagnosed in the ED, and a resident admitted with a documented skin alteration that was not treated or assessed by the facility.
Failure to Assess, Treat, and Prevent Pressure Injuries
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new pressure injuries from developing for three sampled residents. The report states that R14 was at risk for pressure injuries, had a healed pressure injury on 12/1/25, and then developed two facility-acquired unstageable pressure injuries on the coccyx and buttock area on 12/15/25. R14’s annual MDS dated 12/3/25 reflected increased assistance needs for turning and repositioning and worsening bladder incontinence, but did not identify added interventions such as pressure-relieving devices for the bed or wheelchair or a repositioning program despite the decline in mobility. After the wounds were discovered, the report states they were not comprehensively assessed right away and R14’s plan of care was not revised to reflect the change in condition. R14 reported pain in the coccyx/buttock area during the period after discovery. An x-ray on 12/22/25 showed possible osteomyelitis, but the facility did not further assess or treat that finding, and the POAHC was not given timely and accurate information to make an informed decision about care. R14 was later transferred to the hospital on 12/28/25 for progressive decline that included infection, and the ED note documented a necrotic sacral ulcer the size of a fist. The report also describes similar failures for R15 and R32. R15 was admitted at risk for pressure injuries, was dependent on staff for bed mobility and repositioning, and developed an avoidable unstageable pressure injury to the left elbow on 3/10/26. Although preventative measures were in place before the injury, pressure-relieving interventions were not immediately added after the wound was found, and the care plan was not updated until 3/18/26; during the survey, R15 was observed without the pressure-relieving interventions listed in the plan of care. R32, who had contractures to both hands, developed an avoidable facility-acquired stage 3 pressure injury when fingernails became embedded in the palm. R32’s plan of care was not updated to include staff trimming fingernails, and the pressure injury was not comprehensively assessed when first discovered.
Failure to Provide Adequate Supervision and Fall Management
Penalty
Summary
The facility did not ensure adequate supervision and assistance to prevent accidents for residents with known fall risk and mobility limitations. R11, who had diagnoses including a history of subarachnoid hemorrhage and aneurysm with clipping, chronic Foley catheter, intrabdominal drain, hemiplegia, hemiparesis, and muscle weakness, was assessed as dependent on staff for all ADLs and to roll left to right. After an unwitnessed fall on 2/13/2026, R11 was found on the floor beside the bed and was sent to the ER, but no immediate interventions were implemented, no fall investigation was completed, no root cause was determined, and the fall care plan was not reviewed or revised. R11 then had another unwitnessed fall on 2/14/2026 and was found face down on the floor with a laceration to the eye lid and blood present; R11 was transported to the ER and later diagnosed with a traumatic intracranial hemorrhage requiring admission to a Neurology ICU. R5, who had congenital hydrocephalus, bilateral upper and lower extremity contractures, osteoarthritis, a history of falls and seizures, and was documented as dependent on staff for all cares, was also not provided appropriate supervision during bed care. The significant change MDS documented dependence for toileting, transfers, eating, and dressing, and the care plan directed that two staff members be present during cares and interactions, with a Hoyer lift requiring two staff for transfers. On 4/5/2026, CNA-X performed cares alone while R5 was in bed, turned away to get supplies, and R5 rolled out of bed onto the floor. R5 was later sent to the ER and diagnosed with bilateral tibia and fibula fractures. The record also showed conflicting documentation about whether R5 required one or two staff for certain cares, and staff statements indicated R5 had severe contractures and impulsive movements. R13 also experienced deficient fall management. R13 had dementia, muscle weakness, moderate cognitive impairment, and required partial to moderate assistance with mobility and transfers. After an unwitnessed fall on 3/16/2026, no root cause was identified and interventions were not implemented. R13 then had another unwitnessed fall on 3/24/2026, and neurological checks were not completed because there was no nurse available, according to the facility's documentation.
Insufficient Nursing and CNA Staffing
Penalty
Summary
Sufficient nursing staff was not provided to meet resident needs, and the facility did not ensure that staffing levels matched its staffing plan and staffing patterns. The facility assessment, approved 08/29/2025, stated that staffing decisions were based on the facility assessment and resident needs to ensure there were enough staff to care for residents. During interview, the Scheduler stated the facility staffed CNAs based on census and resident acuity and had transitioned CNA shifts from 12-hour shifts to 8-hour shifts in early March 2026, using 10 CNAs for first shift, 10 CNAs for second shift, and 7 CNAs for third shift. Surveyor review of staffing patterns from 02/01/2026 through 04/14/2026 showed multiple staffing shortages, including one CNA short on PM shift on 02/14/2026, one CNA short on PM shift on 02/16/2026, one CNA short on PM shift on 03/02/2026, one nurse short on PM shift and one CNA short on 03/06/2026 due to a no call/no show, one CNA short on PM shift and one CNA short on night shift on 03/13/2026, and two CNAs short on night shift on 03/20/2026. When asked who passed medications on the unit when the nurse did not report for the PM shift on 03/06/2026, the Scheduler stated she did not know. The facility confirmed the staffing shortages during the exit meeting.
Infection Surveillance and Glucometer Disinfection Failures
Penalty
Summary
The facility did not implement an effective infection prevention and control program because it lacked documented infection surveillance for January, February, and March 2026. The facility’s Infection Surveillance policy states that surveillance is a core activity of the Infection Prevention and Control Program and that the Infection Preventionist maintains documentation of incidents, findings, and corrective actions. During the exit meeting, surveyors requested the last 6 months of surveillance documentation, and the facility provided records for November 2025, December 2025, and April 2026, but could not locate March 2026 documentation. January and February 2026 were not documented on the surveillance form, and no documentation of infection surveillance for those three months was available. The IP responsible during that period was no longer at the facility. Surveyors noted that the facility did not have a system of surveillance designed to identify possible communicable diseases or infections before they could spread to other persons in the facility. The facility’s Infection Prevention and Control Program policy states that surveillance is used for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, volunteers, visitors, and others providing services under contract. No additional documentation was provided when the concern was discussed with facility leadership. The facility also did not follow its glucometer cleaning and disinfection procedure during blood glucose testing for R20, a resident with type 2 diabetes mellitus. R20’s record included orders for insulin aspart sliding scale coverage and monitoring for signs and symptoms related to immunodeficiency. During observation, an LPN wiped the shared glucometer with an alcohol wipe pad, obtained R20’s blood glucose, then wiped the glucometer again with an alcohol wipe pad and placed it in the cart drawer. The LPN stated the glucometer was shared by residents on the unit and that alcohol wipe pads were used unless disinfectant wipes were available. The unit manager stated the glucometers were shared and not assigned to individual residents, and surveyors identified that the glucometer was not cleaned with the proper disinfection process between residents.
Missing Required Communication Training for Direct Care Staff
Penalty
Summary
The facility did not ensure that 5 of 5 direct care staff reviewed received the required communication training. The staff reviewed were CNAs TT, UU, VV, WW, and XX, all of whom had worked at the facility for longer than 1 year. The facility policy titled Training Requirements, last revised 1/1/25, states that training content includes effective communication for direct care staff and that documentation of required training is to be forwarded to HR for placement in the personnel file. On 5/4/26, the surveyor reviewed the records for the 5 CNAs and found the facility was unable to provide evidence that they had received the required communication training. On 5/5/26, the HR Director stated that HR handled new-employee onboarding but did not track annual trainings after hire, and that annual training should be kept track of by nursing. The HR Director also stated there was currently no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations confirmed the facility had no evidence of communication training being provided and stated training records were in boxes kept by the previous DON, with no organized system for employee trainings.
Missing Resident Rights Training for Direct Care Staff
Penalty
Summary
The facility did not ensure that direct care staff received the required resident rights training. Based on interview and record review, 5 of 5 Certified Nursing Assistants reviewed—TT, UU, VV, WW, and XX—had worked at the facility for more than 1 year and the facility was unable to provide evidence that they had received resident rights training. The facility policy titled, Training Requirements, states that training content includes resident rights and facility responsibilities for caring for residents, and that documentation of required training is to be forwarded to HR for placement in the personnel file. On 5/4/26, the surveyor reviewed the records of the five CNAs selected from a list of employees provided by the facility. The CNAs had hire dates of 12/4/2024, 10/30/2024, 12/4/2024, 5/7/2024, and 10/30/2024, respectively, and the facility could not provide evidence of the required resident rights training for any of them. During interviews on 5/5/26, the HR Director stated that HR handled new-employee onboarding but did not track annual trainings after hire, and said there was currently no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations confirmed the facility had no evidence that resident rights training had been provided and stated that training records were in boxes kept by the previous DON, with no organized system for employee trainings.
Missing Required Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility did not ensure that 5 of 5 direct care staff reviewed received the required training on abuse, neglect, and exploitation. The staff members identified were CNAs TT, UU, VV, WW, and XX, all of whom had worked at the facility for more than 1 year. The facility was unable to provide evidence that these CNAs had received training on abuse, neglect, and exploitation, despite the facility policy stating that training content includes abuse, neglect, and exploitation prevention, dementia management and care of the cognitively impaired, and other required topics. On 5/4/26, the surveyor reviewed the records of the 5 CNAs selected from a list of employees provided by the facility. The surveyor found that CNA TT, CNA UU, CNA VV, CNA WW, and CNA XX had hire dates between 5/7/2024 and 12/4/2024, but no documentation was available showing they had completed the required training. On 5/5/26, the HR Director stated that HR handled new employee onboarding but did not track annual training after hire, and that annual training should be tracked by nursing. The HR Director also stated there was currently no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations confirmed the facility had no evidence that abuse, neglect, and exploitation training had been provided, and the NHA stated the training records were in boxes kept by the previous DON and were not organized. The NHA further confirmed there was no Staff Development Coordinator or designee maintaining a training schedule or documentation system for completed trainings.
Failure to Provide Required QAPI Training
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) program was not provided to 5 of 5 direct care staff reviewed. The surveyor reviewed CNA TT, UU, VV, WW, and XX, all of whom had worked at the facility for longer than 1 year, and the facility was unable to provide evidence that any of them had received the required QAPI training. The facility policy dated as revised 1/1/25 states that training content includes, at a minimum, the elements and goals of the facility’s QAPI program and that documentation of required training is to be forwarded to HR for placement in the personnel file. On 5/4/26, the surveyor reviewed the five CNAs from a list of employees provided by the facility and checked their annual performance reviews and required training records. The facility could not produce evidence of QAPI training for any of the five staff members. On 5/5/26, the HR Director stated that HR handles new-employee onboarding but not annual training, and that annual training should be tracked by nursing; the HR Director also stated there was currently no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations confirmed there was no evidence of QAPI training being provided and stated that training records were in boxes kept by the previous DON and were not organized, and that no Staff Development Coordinator or designee was maintaining a training schedule or documentation system.
Missing Infection Control Training Documentation for CNAs
Penalty
Summary
The facility did not ensure that required infection prevention and control training was provided to 5 of 5 direct care staff reviewed. The facility’s policy titled, Training Requirements, stated that training content includes written standards, policies, and procedures for the infection prevention and control program, and that documentation of required training is to be forwarded to HR for the personnel file. On 5/4/26, the surveyor reviewed 5 CNAs from the facility’s employee list: CNA-TT, CNA-UU, CNA-VV, CNA-WW, and CNA-XX. These staff members had been hired between 10/30/2024 and 12/4/2024 and had worked at the facility for longer than 1 year, but the facility was unable to provide evidence that any of them had received infection control training. During interviews on 5/5/26, the HR Director stated that HR handled new employee onboarding but did not track annual trainings after hire, and stated there was currently no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations both confirmed there was no evidence that infection control training had been provided to staff. The NHA stated that training records were in boxes kept by the previous DON and that the facility had nothing organized for employee trainings. The NHA also confirmed there was no Staff Development Coordinator or designee maintaining a training schedule or documentation of completed trainings.
Missing Compliance and Ethics Training for Direct Care Staff
Penalty
Summary
The facility did not ensure that 5 of 5 direct care staff reviewed received the required training regarding compliance and ethics. The CNA staff reviewed were TT, UU, VV, WW, and XX, all of whom had worked at the facility for longer than 1 year. The facility's policy, last revised 1/1/25, states that training content includes written standards, policies, and procedures for the facility's compliance and ethics program, and that documentation of required training will be forwarded to HR for placement in the personnel file. On 5/4/26, the surveyor selected the five CNAs from a list of employees provided by the facility and reviewed their annual performance reviews and required training. The facility was unable to provide evidence that any of the five CNAs had received compliance and ethics training. During interviews, the HR Director stated that annual training was tracked by nursing and that there was currently no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations confirmed there was no evidence of compliance and ethics training being provided and stated that training records were in boxes kept by the previous DON, with no organized system or designated staff member maintaining training schedules or documentation.
Missing Annual CNA Training Documentation
Penalty
Summary
The facility did not ensure that 5 of 5 Certified Nursing Assistants completed the required 12 hours of annual training. CNA TT, UU, VV, WW, and XX had all worked at the facility for longer than one year, and the facility was unable to provide evidence that each had completed the required annual training. The surveyor selected these CNAs from a list of employees provided by the facility and reviewed their annual performance reviews and required training records. The facility policy titled Training Requirements, revised 1/1/25, states that the facility is responsible for developing and maintaining an effective training program and that documentation of required training is to be forwarded to HR for placement in the personnel file. During interviews, the HR Director stated that HR handled new employee onboarding only and that annual training was tracked by nursing, but there was no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations both confirmed there was no evidence of the 12 hours of annual training being completed, and the NHA stated that training records were in boxes kept by the previous DON and were not organized.
Failure to Provide Required Behavioral Health Training
Penalty
Summary
The facility did not ensure that required behavioral health training was provided to 5 of 5 direct care staff reviewed. The surveyor reviewed the annual performance reviews and training records for CNA TT, CNA UU, CNA VV, CNA WW, and CNA XX, all of whom had worked at the facility for more than 1 year. The facility was unable to provide evidence that any of these CNAs had received the required behavioral health training. The facility policy titled Training Requirements states that training content includes behavioral health and that training is based on a facility assessment. During interviews, the HR Director stated that HR handled new employee onboarding but did not track annual training, and stated there was no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations confirmed there was no evidence that behavioral health training had been provided and stated that training records were in boxes kept by the previous DON, with no organized system for employee training documentation.
Incomplete Abuse Investigation After Resident Fall and Unexplained Injuries
Penalty
Summary
The facility did not have evidence that all alleged violations of abuse were thoroughly investigated for one resident. The resident had diagnoses including congenital hydrocephalus, bilateral upper and lower extremity contractures, osteoarthritis, a history of falls, and seizures. The resident’s MDS documented dependence for all cares, frequent bowel and bladder incontinence, and moderate cognitive impairment. The care plan identified the resident as high risk for falls and stated the resident required two staff members during cares and interactions. The resident had a fall when a CNA performed cares independently while the resident was lying in bed, and the resident rolled out of bed. The facility’s fall investigation documented that the resident required two-person assistance but care was provided by one staff member. Staff interviews and record review showed that the resident later developed changes in condition, including left ankle deformity, bilateral lower extremity bruising, swelling, and crackling. The resident was sent to the ER, where staff documented extensive bruising under the chin, right forehead, right clavicle, left forearm, and both lower extremities, with injuries that did not correlate to the reported fall. ER findings included bilateral proximal and distal tibia and fibula fractures, and the forensic nurse documented that the ER physician verbally stated the fractures were spiral fractures indicating abuse. The facility began an investigation after police arrived at the facility, but the investigation did not include resident interviews and relied on staff statements from night shift only. Facility leadership stated the investigation was not perfect and that the facility did not suspect abuse, later describing the event as an injury of unknown origin. Interviews also showed delays and incomplete documentation related to the resident’s change in condition after the fall. The surveyor determined the abuse investigation was not thorough because it did not fully investigate the allegation or interview all involved persons and others with knowledge of the event.
Missed Night-Shift Medications on Sparkle Unit
Penalty
Summary
The facility failed to ensure that 13 of 13 sampled residents with scheduled medication administrations on the night shift of 3/6/2026 received their medications as ordered. Survey review of the MARs and TARs for residents on the Sparkle unit showed multiple scheduled medications were not marked as administered after 7:00 p.m., and four residents on the unit had no scheduled night-shift medications after 7:00 p.m. on that date. The missed medications involved residents with a range of diagnoses and ordered treatments, including antihypertensives, insulin, anticoagulants, anticonvulsants, psychotropics, pain medications, respiratory medications, bowel medications, and sleep aids. Examples included R24 missing amlodipine, melatonin, senna-docusate, and ammonium lactate cream; R23 missing Benadryl, gabapentin, Lantus, metoprolol, pravastatin, trazodone, and a 5:00 a.m. amlodipine dose; R21 missing atorvastatin, Lantus, metoprolol succinate, and gabapentin; R22 missing Seroquel, acetaminophen, benztropine, gabapentin, levetiracetam, pramipexole, and senna plus; and R19, R25, R26, R20, R13, R18, R16, R17, and R27 each had multiple ordered medications not documented as given. Survey interviews showed the issue occurred during the night shift on the Sparkle unit. The agency nurse stated there was no nurse covering the back part of the unit until 11:00 p.m., and the LPN who worked 11:00 p.m. to 7:00 a.m. stated no one was on the back cart when the shift started and that the medications were already late, so they were not given. The LPN also stated the Assistant DON was notified, but the physician was not contacted. The Unit Manager stated the issue had not been noticed and that the physicians were not called because staff did not know about the problem.
Failure to Notify Physician and Representatives of Significant Changes
Penalty
Summary
The facility failed to ensure that the resident, the resident’s physician, and/or the resident’s representative were notified when changes in condition occurred for three residents. The report cites the facility policy requiring prompt notification of the resident, consultation with the physician, and notification of the resident’s representative when there is a change requiring notification, including accidents, significant decline, or circumstances requiring a change in treatment. For one resident, the record showed a 20 lb. weight loss between the hospital admission weight and the weight obtained on 4/8/2026. The resident had diagnoses including type 2 diabetes mellitus, dementia, COPD, CKD stage 3, obesity, and nutritional risk. The care plan included monitoring weights and reporting lab/diagnostic results to the MD. Survey review found no admission weight documented, missed weights on 3/26/2026 and 4/1/2026, no documentation that the resident refused weights, and no documentation that the physician was notified of the missed weights or the weight loss. The RD stated the weight loss was discussed in IDT review, but the physician was not contacted and no eINTERACT change-in-condition form was found. For another resident, the record documented a fall from bed with injury while care was being performed by one CNA instead of the required two-person assistance. The fall investigation identified that the resident had a high fall risk and that care was performed with only one staff member. The community RN case manager stated he was not notified until several days later and that notification within 24 hours was expected for a significant change or fall. For the third resident, who had an activated HCPOA and pressure injuries to the coccyx, the record showed wound decline, abnormal imaging that could not exclude osteomyelitis, wound treatment changes, and a diet downgrade after pocketing food. Survey review found no documentation that the HCPOA was notified of the wound being assessed as healed, the wound decline and infection-related treatment changes, or the diet change.
Grievance on SNF Referrals Not Fully Investigated or Communicated
Penalty
Summary
The facility did not ensure a resident’s grievance was thoroughly investigated, that pertinent findings or conclusions were documented, or that the outcome was communicated to the resident. The issue involved a resident who was admitted and later readmitted to the facility and was their own person. The resident voiced a grievance related to requesting referrals to two other SNFs, and during interview stated they had provided the facility with the names of the two SNFs and had not received documentation showing the referrals were made. The resident also stated this had been ongoing for months. Record review showed a social worker note documenting that two referrals were made, but there was no documentation of the results of those referrals. A later social worker note documented that one SNF had no beds available and the other was still pending, with no further documentation of the outcome. The grievance log documented a grievance report for the resident with a summary stating one SNF had no long-term beds and one was still pending, and the grievance was documented as resolved with the resident. However, there was no documentation identifying who was contacted at the two SNFs or what documents or paperwork were sent as part of the referral request. The current social worker stated they were not aware of the resident’s SNF referrals.
Incomplete Comprehensive Assessment and CAA Analysis
Penalty
Summary
The facility did not ensure a comprehensive assessment was completed for one resident, including analysis of findings needed to develop a plan of care. The resident had an annual comprehensive MDS with an assessment reference date of 12/3/25 that identified changes in bladder continence and mobility. The resident was assessed as understanding others and being able to be understood, but the cognitive interview showed severe impairment. The resident used a wheelchair, was dependent on staff for all ADLs except set-up assistance for eating, and had a decline in bladder continence from occasionally incontinent to always incontinent. The resident also had one unhealed stage 2 pressure injury and three venous or arterial wounds. The CAA summary indicated multiple triggered areas, including cognitive loss/dementia, urinary incontinence and indwelling catheter, behavioral symptoms, falls, nutritional status, dental care, pressure ulcer, and psychotropic drug use. However, several CAAs did not contain a complete analysis of the resident’s individual needs or a specific rationale tied to the resident’s condition. The cognitive loss/dementia CAA noted severe impairment and behavioral symptoms, but the section for input from the resident or family was blank and the overall objective was not documented. The urinary incontinence CAA identified the resident as always incontinent, but the type of incontinence was blank and the care plan did not address the resident’s bladder continence status. The behavioral symptoms CAA also had blank sections for the nature of the problem, seriousness, contributing factors, and resident or family input, while the rationale simply stated to proceed to care plan. Other triggered CAAs were similarly incomplete. The falls CAA had blank sections for history of falling, physical performance, laboratory tests, environmental factors, and resident or family input, and the rationale repeated the same generic statement used in other CAAs. The nutrition CAA identified obesity, prior weight loss, mechanically altered diet, Boost supplement use, dysphagia, broken teeth, and multiple contributing diagnoses, but the dietitian did not document a summary or rationale. The pressure injury, dental care, and psychotropic drug use CAAs also contained blank sections or generic rationales that did not provide a resident-specific analysis. During interview, MDS nurses stated they review the record, ask questions, and may assess the resident, but also stated that care plans are completed by nurse managers and that assessment details from the MDS are not shared in a collaborative process to establish the plan of care for the resident.
Care Plans Not Updated After Changes in Resident Condition
Penalty
Summary
The facility did not ensure that the comprehensive care plans for 2 of 16 sampled residents were reviewed and revised by the interdisciplinary team after changes in condition. The facility policy stated that the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and that the plan would include resident-specific interventions reflecting the resident’s needs and preferences. One resident was admitted with diagnoses including history of subarachnoid hemorrhage and aneurysm status post clipping, chronic Foley catheter, intrabdominal drain, hemiplegia, hemiparesis, and muscle weakness. The resident’s admission MDS documented severely impaired cognition, impairment on one side of the upper and lower extremities, dependence on staff for all ADLs, and dependence on staff to roll left to right. The resident’s fall risk changed from low on admission to moderate on a later assessment, and the resident experienced falls on 2/13/26 and 2/14/26. Survey review found that the resident’s care plan was not updated or revised after either fall to reflect person-centered interventions to prevent additional falls. The second resident’s annual and quarterly MDS assessments documented severe cognitive impairment, dependence on staff for most ADLs, decline in mobility, and worsening bladder incontinence. The resident was assessed as needing substantial to maximal assistance for rolling in bed and as dependent for other mobility tasks, but the care plan was not revised to address the increased assistance needed for bed mobility. The resident also had pressure injury risk, an unstageable coccyx pressure injury, and osteomyelitis. Nursing notes documented repositioning every 2 hours, but the skin integrity and ADL care plans were not updated to include an individualized repositioning plan. The incontinence care plan also was not individualized to identify the type of incontinence, possible voiding pattern, or toileting/check-and-change frequency despite the resident being assessed as always incontinent of bladder.
Failure to Maintain Nail Care and Hand Hygiene for a Dependent Resident with Hand Contractures
Penalty
Summary
The facility did not always ensure that a dependent resident with significant bilateral hand contractures received the necessary assistance with hand hygiene and nail care to maintain skin integrity. The resident was admitted with diagnoses including Parkinson’s disease, muscle weakness, contractures of both hands, and dementia, and the MDS documented moderate cognitive impairment and full dependence on staff for all ADLs. The care plan identified the resident as total care for personal hygiene and included interventions for protective gauze to the left palm, carrot splints to both hands, and keeping fingernails short, with family listed as responsible for nail care. Weekly shower sheets showed inconsistent documentation of fingernail care, with several entries left blank and only two entries indicating nails were cut. On 4/20/26, OT documented that the resident had a wound on the left palm due to fingernail length and contracture and that the resident was not wearing the left carrot splint because of the wound. Nursing documentation from the same day stated that the fingernail was embedded in the palm, the resident complained of pain and discomfort, gauze was placed in the hand, and the provider and wound care team were notified. The grievance log reflected that the family raised concern about proper hygiene because the fingernail had become embedded in the hand, and the summary noted that floor staff would maintain fingernail care and hygiene. The resident’s plan of care was not updated to reflect that staff were to provide nail care, and it continued to list the family as responsible. At exit, the facility did not provide additional evidence that nail care had been provided by staff since the last documented nail care entry.
Missing Foley Catheter Orders and Care Plan
Penalty
Summary
The facility did not ensure appropriate care and services for a resident with a Foley catheter because there was no physician order or documented indication for its use. The resident was readmitted with diagnoses including urinary tract infection, neuromuscular dysfunction of the bladder, and retention of urine, and was observed in bed with a Foley catheter bag containing urine. During interview, the resident stated they did not know how long they had had the catheter, believed it had been over a year, and said they had never seen a urologist despite asking staff about it. Review of the medical record showed the resident’s current physician orders and plan of care summary did not document a Foley catheter. Surveyors were unable to locate any physician orders or a plan of care for the catheter or catheter care and services. A CNS reviewed the record and stated the resident had previous catheter orders before readmission, but there were no catheter indications for use, care and services, or physician orders put in place when the resident returned to the facility. The CNS stated there should have been physician orders for the Foley catheter.
Failure to Obtain Admission Weight and Follow Ordered Weight Monitoring
Penalty
Summary
The facility did not ensure that a resident maintained acceptable nutritional status because the resident did not have an admission weight obtained at the facility and the documented weight monitoring was not completed as ordered. The resident was admitted with diagnoses including type 2 diabetes mellitus, muscle weakness, cognitive communication deficit, dementia, major depressive disorder, anxiety disorder, and COPD. The admission MDS documented a BIMS score of 13, indicating the resident was cognitively intact, and the care plan included monitoring intake, providing ordered diet and supplements, and weighing the resident as ordered or per facility protocol. The physician ordered a weight on admission and then weekly for four weeks, but the only facility-documented weight located was 183.8 lbs. on 4/8/2026. Survey review found no admission weight on the day of admission, and the MAR/TAR documented that weight was not obtained on 3/26/2026 and 4/1/2026. There was no nursing progress note showing the resident refused a weight. The RD stated an admission weight had not been documented, so the hospital discharge weight of 203.7 lbs. was reviewed instead, and the RD requested a weight be obtained. When the resident was later weighed, the documented weight was 183.8 lbs., which reflected a 19.9 to 20 lb. loss from the hospital discharge weight. The RD stated a re-weight should ideally be obtained within 24 to 48 hours, but the resident discharged before that occurred. Interviews with nursing leadership showed staff were expected to obtain a weight on admission when able and document refusals if they occurred, but no documentation showed that happened for this resident. The 24-hour board did not show a request for a re-weight, and the NHA stated the resident should have been weighed on admission and re-evaluated after the 20 lb. discrepancy was identified. The resident's nutritional risk care plan was not revised with new interventions after the weight loss was identified, and the facility did not obtain the additional weight requested by the RD.
Failure to Provide Social Services for Hospice and Care Coordination
Penalty
Summary
The facility did not provide medically related social services to a resident with an activated POAHC who experienced significant clinical decline. The resident had multiple diagnoses including metabolic encephalopathy, seizures, dementia, COPD, asthma, AKI, anemia, hypothyroidism, hypertension, hyperlipidemia, hypotension, Type II diabetes, chronic pain, bipolar type 2, paranoid schizophrenia, anxiety, depression, dehydration, and bacteriuria. The resident was wheelchair dependent, required extensive assistance with ADLs, had severely impaired cognition on MDS testing, and later developed worsening wounds, swallowing difficulty, and a change in nutritional needs. The record showed the resident developed pressure injuries, venous wounds, and a wound infection, with x-ray findings that could not rule out osteomyelitis. A NP documented that the resident was declining, pocketing food, and had significant swallowing difficulties, and hospice was discussed and initiated with the POAHC. However, there was no documentation of Social Services involvement in the resident’s clinical changes, hospice referral process, or communication with the POAHC about end-of-life care, treatment options, or test results. The record also lacked social services documentation after an early December note stating the resident would remain LTC until alternate placement was found. Interview information indicated the POAHC did not agree to hospice services and was not aware of the wound infection or intake concerns. The NP stated the hospice agency was selected without options being provided to the POAHC and that end-of-life care and treatment were ordered and implemented without the POAHC’s consent. Survey review found no documentation that Social Services participated in discussions about the resident’s clinical changes, hospice referral, or discharge planning.
Missed antihypertensive dose when contingency supply was not checked
Penalty
Summary
The facility did not ensure accurate and safe medication administration for one resident when Amlodipine Besylate 5 mg ordered for hypertension was unavailable and the medication was not given. The resident had diagnoses including hypertension, cerebral infarction, dementia, type 2 diabetes mellitus, dysphagia, and chronic kidney disease stage 4, and the MDS documented a BIMS score of 08 with moderate cognitive impairment. The physician order directed Amlodipine Besylate Oral Tablet 5 mg by mouth in the morning for hypertension, and the MAR documented that the 4/14/2026 dose was not administered. During observed medication administration, the LPN could not locate the resident’s amlodipine medication card and called the pharmacy, which stated the medication would be sent out that night. The LPN did not use contingency medications to determine whether the medication was available at the facility and did not notify the physician about the missing medication. On interview the next day, the Unit Manager stated the facility follows up on missed medications the day after they are not administered and acknowledged that contingency should have been checked, but there was no list of medications available. Surveyor notification to nursing leadership occurred later that day, and no additional information was provided regarding why the medication was not available as ordered.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility did not ensure the medication error rate remained below 5% for 2 of 6 residents observed receiving medications, and the overall medication error rate was 12%. During observation, R29 was given one 81 mg enteric coated aspirin even though the physician order documented aspirin 81 oral tablet chewable, 81 mg by mouth in the morning for NSTEMI. The report noted that chewable aspirin is intended for rapid absorption, while enteric-coated aspirin is delayed release and used to reduce gastrointestinal irritation. R24 was also observed receiving medication errors. RN-S administered one 81 mg chewable aspirin even though the physician order documented aspirin EC delayed release 81 mg, 1 tablet by mouth in the morning for heart disease. RN-S also administered one senna 8.6 mg even though the physician order documented senna-docusate sodium 8.6-50 mg, 1 tablet by mouth two times a day for constipation. The report states that senna is a stimulant laxative, while senna-docusate combines a stimulant with a stool softener. On interview, the Unit Manager stated education would be provided, and the end-of-day meeting included notification that the medication error rate was 12% due to the incorrect aspirin types and the incorrect senna formulation.
Unlabeled insulin pens found on medication cart
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with currently accepted professional principles. During observation, interview, and record review, surveyors found three insulin pens in a drawer on the Sparkle front unit medication cart that did not have resident names or dates showing when the pens were opened or when they expired. The facility policy titled "Insulin Pen" states that insulin pens are for a single resident only and must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. At 8:36 a.m., a surveyor observed LPN-Q's medication cart on the Sparkle front unit and saw the unlabeled insulin pens in the cart drawer. When asked how staff would know which resident the pens belonged to, LPN-Q stated that staff don't know. At 8:40 a.m., the surveyor interviewed UM-T about the unlabeled pens, and UM-T and the surveyor went to the cart and removed the insulin pens. Later that day, the surveyor informed the Clinical Nurse Specialist-B and Nursing Home Administrator-A of the concern that the insulin pens were not labeled with the resident name or the date opened or expired, and no additional information was provided about why the facility did not ensure the pens were labeled according to professional principles.
Unapproved Diet Downgrade Without Assessment
Penalty
Summary
The facility did not ensure a resident’s change in diet consistency was comprehensively assessed or supported by physician or Registered Dietitian documentation after a change in condition. R14, who had diagnoses including metabolic encephalopathy, seizures, senile dementia, COPD, asthma, AKI, anemia, bipolar type 2, paranoid schizophrenia, anxiety, depression, dehydration, and bacteriuria, was documented on care plans and MDS assessments as needing set-up assistance for eating and being on a mechanically altered diet due to dysphagia. The nutrition care plan also identified risks related to obesity, fluid shifts, and impaired skin integrity, and nursing documentation showed physician orders to monitor for pocketing food every shift. On 12/23/25, an LPN documented that R14 was pocketing food and that the diet was downgraded to pureed with nectar liquids. However, there was no documentation that a swallowing assessment or other comprehensive assessment was completed for the diet change, and there was no physician order or RD order supporting the downgrade. The dietary department later had a Diet Change Form for pureed consistency and nectar thick liquids, but the record did not show an order authorizing the change. During interviews, the RD stated she completed a nutritional assessment and was not aware of eating concerns or diet changes for R14. The DOR stated R14 had not received therapy services since 10/2/25 and had no referral or assessment for speech therapy related to swallowing changes. The NP later documented that R14 had significant swallowing difficulties and that the diet was downgraded, but the surveyor noted the record still lacked documentation of an order or swallowing assessment for the consistency change.
Failure to Offer and Administer Requested Influenza Vaccine
Penalty
Summary
The facility failed to offer the influenza immunization to one resident who requested it. The resident was admitted with end stage renal disease requiring dialysis, dependence on renal dialysis, type 2 diabetes, asthma, and chronic respiratory failure with hypoxia. Survey review of the electronic medical record found no documentation that the resident was offered, declined, or received the influenza vaccine, and no documentation that the resident received education about the benefits or potential side effects of accepting or declining the immunization. The resident’s progress note documented that the resident elected to receive both the flu and COVID vaccines for the upcoming year and that consents were completed. However, surveyors could not locate any record showing that the influenza vaccine was actually administered after that election. When the issue was discussed with the Clinical Nurse Specialist, Director of Operations, and Nursing Home Administrator, the Director of Operations reviewed the record and confirmed that the resident declined the COVID vaccine but wanted the influenza vaccine, and also confirmed that the resident did not receive the influenza vaccine.
Failure to Provide Timely and Consistent Care, Monitoring, and Treatment
Penalty
Summary
Three residents did not receive necessary care and treatment as required by physician orders, facility policy, and their individual care plans. One resident with chronic kidney disease, diabetes, and a history of pressure injuries did not have weekly skin assessments completed for three weeks. When a new skin impairment was observed, there was no comprehensive assessment, no treatment initiated, and no care plan revision at the time the issue was first identified. Documentation was inconsistent, and the wound was not properly classified or communicated to all relevant parties until several days later. Another resident with heart failure and fluid overload had physician orders for daily weights and strict fluid intake monitoring. However, fluid intake was not consistently documented, with many days missing numerical values or any record at all. Daily weights were also not consistently recorded, and staff interviews revealed a lack of clarity and compliance with documentation procedures. The resident's care plan and Kardex did not consistently reflect the fluid restriction order, and staff were not always aware of or following the monitoring requirements. A third resident with a urinary tract infection and pressure ulcer had a urinalysis ordered, but the specimen was not processed for over a week due to improper labeling. This resulted in a delay in diagnosis and treatment, as the antibiotic was not ordered until after the test was finally completed. Staff interviews confirmed that the labeling error and lack of timely communication with the laboratory led to the delay in processing the specimen and initiating appropriate treatment.
Failure to Assess and Monitor Skin Integrity in High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor the skin condition of a resident who was at high risk for pressure injuries. The resident had multiple diagnoses, including End Stage Renal Disease requiring dialysis, Diabetes Mellitus, and severe calorie malnutrition, all of which increased their risk for pressure injuries. Despite these risk factors and a documented decline in the resident's health status, the facility did not update the plan of care or conduct additional skin assessments when the resident began refusing dialysis, medications, and meals. The last documented licensed nurse skin assessment was completed several weeks prior to the resident's significant health decline. The facility's policy required regular skin assessments and updates to the care plan when a resident's condition changed, but these were not performed. Staff interviews revealed that the wound care nurse only assessed a toe abrasion and did not examine other areas of the resident's body, including the heels or hips. Other staff members, including the nurse manager and nurse practitioner, acknowledged that no comprehensive skin assessment was conducted during the period of the resident's decline, despite increased refusals of care and a need for greater assistance with activities of daily living. When the resident was eventually transferred to the hospital, emergency department documentation and photographs identified four pressure injuries, including unstageable injuries to the hip and back, a stage 1 injury to the ischium, and a deep tissue injury to the heel. Facility records lacked documentation of weekly skin assessments or any revisions to the plan of care in response to the resident's deteriorating condition and increased risk factors. Interviews with facility staff confirmed that no additional skin assessments were performed during this critical period.
Missed Medication Doses Due to Unavailability and Lack of Follow-Up
Penalty
Summary
A deficiency occurred when a resident with diagnoses including heart failure and fluid overload did not receive nine doses of an ordered eye drop medication, Tetrahydrozoline solution, over a period of several days. The resident, who was cognitively intact and did not refuse care, reported to the surveyor that the eye drops were not administered for almost a week. Review of the Medication Administration Record confirmed that the medication was not given from 11/26/2025 to 11/30/2025 due to the medication being unavailable and not reordered in a timely manner. No follow-up was conducted to ensure the medication was obtained during this period.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents who required such services, resulting in harm. One resident was admitted following hospitalization for multiple fractures and had a history of pain, anxiety, and depression. Upon admission, this resident did not receive prescribed pain medications due to issues with obtaining valid prescriptions from the hospital and delays in entering the resident into the pharmacy system. The resident experienced severe, uncontrolled pain and was ultimately sent back to the emergency room for pain management. Documentation showed that the resident's pain was not adequately addressed upon arrival, and staff were unable to access the facility's emergency medication supply due to the lack of valid prescriptions and authorization codes from the pharmacy. Another resident was admitted with a fracture and had orders for multiple pain medications, including Roxicodone, Tramadol, and acetaminophen. Despite these orders, the resident did not receive the prescribed narcotic pain medications because the scripts were not received by the pharmacy in a timely manner. Staff administered acetaminophen for pain, but there was inconsistent documentation of pain assessments and medication administration. The resident reported severe pain and repeatedly stated that prescribed pain medications were not available. Staff interviews revealed confusion about the process for obtaining and administering narcotic medications from the emergency supply, and the resident's pain was not effectively managed until the correct medications were finally delivered and administered. In both cases, the facility's failure to ensure timely receipt and administration of prescribed pain medications, as well as inadequate communication and documentation, led to residents experiencing unnecessary pain. The facility's own pain management policy required prompt evaluation and intervention for pain, but these procedures were not followed, resulting in harm to the residents involved.
Food Safety and Sanitation Deficiencies in Kitchen and Pantry
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in several key areas. Observations revealed that milk gallons were repeatedly stored on the counter in the 300-hall dining room without refrigeration or ice, resulting in milk temperatures above the required 41 degrees Fahrenheit. These findings were confirmed by an LPN who verified the elevated temperatures after meal service. Additionally, the pantry refrigerator in the 400-hall was found to be dirty, containing undated and unlabeled food items, including sandwiches and a brown liquid in an ice tray. The Certified Medication Aide acknowledged the unsanitary conditions and disposed of the questionable food items during the survey. Further inspection of the main kitchen uncovered significant cleanliness issues. The floor beneath equipment such as the hot plate warming storage system and oven was dirty with food debris and grime. The sandwich station, ice machine, and walls behind sinks and food stations were also found to be unclean, with food spatter and brown stains present. The Food Service Director admitted that some areas had not been cleaned for about a month and that certain surfaces, like the walls, were not included in the cleaning schedule. Drinking glasses were observed to have a hard water film, and the director was unsure how to remove these stains. Review of facility records and interviews revealed that there was no documentation of hot holding temperatures for food on the tray line, as required by policy and the FDA Food Code. The staff only recorded cooking temperatures and did not monitor or document holding temperatures during food service. The Registered Dietitian confirmed ongoing issues with kitchen and pantry cleanliness and stated that the kitchen was responsible for monitoring the pantry refrigerator. The facility lacked policies or schedules for cleaning key kitchen areas and for checking food temperatures throughout food service, contributing to the deficiencies observed.
Improper Management of Exterior Trash Area
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse in the exterior trash area, as observed during a survey. Two trash bins located outside near the kitchen, one for recycling and one for trash, were found with all lids open and surrounded by trash debris, including gloves, a mask, and an empty plastic container. The trash bin designated for trash was also overflowing with trash bags. The Food Service Director acknowledged that the lids should have been closed and the debris cleaned, noting that dietary staff took out the trash after each meal. The Registered Dietitian stated she did not check the trash area, and the Administrator confirmed there was no policy in place for trash management. All 116 residents in the facility had the potential to be affected by this deficiency, as the improper management of the trash area could contribute to pest infestation. No specific residents or their medical conditions were mentioned in the report.
Failure to Implement QAPI Process for Repeated Deficiencies
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) process to address previously identified deficient practices, resulting in continued noncompliance. During a survey, it was found that the facility had been cited for deficiencies related to food palatability, proper garbage/refuse disposal, and infection prevention and control in a prior survey, and these same issues were cited again in a subsequent survey. The Administrator acknowledged that while survey results were used to identify areas needing improvement, the facility had not developed or implemented performance plans for these deficiencies. Specifically, there were no metrics or monitoring tools for food palatability, garbage disposal issues were not revisited or addressed with new corrective measures, and infection control improvements were limited to education on enhanced barrier precautions without broader performance improvement projects. Review of the facility's QAPI policy indicated that all identified problems should be addressed and prioritized, with actions documented and monitored through QAA Committee meetings. However, interviews and record reviews revealed that the facility did not follow its own policy, as there was a lack of documented improvement plans and ongoing monitoring for the cited deficiencies. This failure to act on identified problems through the QAPI process led to repeated citations for the same issues affecting all residents in the facility.
Failure to Serve Palatable Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was palatable and served at a safe and appetizing temperature for five cognitively intact residents. Multiple residents reported that their meals were often cold or lukewarm, with some noting that changes in the kitchen or delivery system had resulted in more frequent cold meals. Resident council notes also documented complaints about milk sitting out all day and food being cold due to delayed delivery. These concerns were corroborated by interviews with residents and the Registered Dietitian, who confirmed an increase in complaints about cold food and the absence of a pellet system to keep food hot. Direct observations of meal service revealed that while food temperatures were within appropriate ranges when initially prepared in the kitchen, significant drops in temperature occurred by the time meals were served. For example, a test tray plated and placed on a cart showed hot food items dropping below the expected 130 degrees Fahrenheit by the time they were served, with cold items also exceeding the recommended temperature. The facility's policy required food to be served at safe and appetizing temperatures, but the observed practices and resident feedback indicated this standard was not consistently met.
Delayed Call Light Response for Multiple Residents
Penalty
Summary
The facility failed to ensure timely response to call lights for five out of 46 residents, resulting in prolonged wait times for assistance. Multiple residents reported and were observed experiencing significant delays, with call light response times documented as exceeding 20 minutes on several occasions, and in some cases, reaching up to 45 minutes. Staff interviews confirmed that call lights were not always answered promptly, particularly during periods of short staffing or when staff were engaged in other duties such as passing meal trays. Observations revealed that staff sometimes walked past illuminated call lights without responding, and that there was no pager system in place to alert staff to active call lights outside of the nurses' station. Residents affected by these delays included individuals with various medical conditions such as femur fracture, asthma, muscle weakness, urinary tract infection, chronic kidney disease, diabetes, sepsis, prostate cancer, repeated falls, end stage renal disease, and others. Some residents were cognitively intact, while others had moderate cognitive impairment. Residents described waiting over an hour for assistance, including instances where they remained in soiled conditions due to incontinence until staff responded. Call light data reports corroborated these accounts, showing multiple instances of extended response times across different dates and shifts. Staff interviews indicated that the unit was often staffed with only one CNA, which was insufficient to meet the needs of residents with high medical acuity and complex care requirements. Staff acknowledged that all personnel were expected to respond to call lights, but this expectation was not consistently met. The DON stated that response times exceeding 20 minutes were not acceptable, yet documented response times frequently surpassed this threshold. Resident Council notes further reflected resident concerns about insufficient staff assistance and infrequent rounding.
Failure to Assess and Supervise Resident Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, hypertension, and left arm pain was readmitted to the facility and assessed as moderately cognitively impaired, with a BIMS score of 11 out of 15. The resident did not have a care plan for self-administration of medications, nor was there a physician's order permitting self-administration documented in the electronic medical record. Despite this, during a medication pass, an RN prepared the resident's medications, placed them in a medicine cup, and left the room to retrieve additional Tylenol, leaving the resident unobserved with the medications. The resident then self-administered the medications without direct nurse supervision. Interviews with the RN and the Director of Nursing confirmed that the resident was not authorized to self-administer medications and that facility policy requires nurses to observe residents taking their medications. Review of facility policies further indicated that self-administration must be assessed and documented, and that medication administration should be directly observed by nursing staff. These actions and omissions resulted in a failure to ensure the resident was safe to self-administer medications and that medication administration was properly supervised and documented.
Failure to Provide Scheduled Baths or Showers Due to Facility Water Issues
Penalty
Summary
The facility failed to provide scheduled baths or showers to three residents who required assistance with bathing, as evidenced by documentation and interviews. One resident with end stage renal disease, diabetes, and other conditions did not receive weekly baths or showers on multiple occasions, as shown in the electronic medical record. This resident was cognitively intact and required substantial to maximum assistance for bathing. The resident reported that there was no hot water and no showers available. Another resident with a history of fractures, dialysis dependence, and anxiety also did not receive weekly baths or showers as scheduled, with documentation showing missed bathing dates and substitution of bed baths due to lack of hot water. Staff interviews confirmed that some rooms lacked hot water, requiring alternative bathing methods such as basin baths or using water from other sources. The DON was unable to confirm whether showers or baths had occurred as scheduled for this resident. A third resident, admitted after fractures and requiring maximum assistance with bathing, reported feeling dirty and having received only one bed bath since admission, with no hair washing. Documentation confirmed the absence of showers or bed baths for this resident during the review period. Staff interviews revealed that the resident had not been offered a bath or shower, and that cold water in the shower room led most residents to choose bed baths, though this resident had not been offered one. The DON stated there was no reason for the missed baths or showers and expected staff to follow the bathing schedule and resident preferences.
Lab Tests Performed Without Physician Order
Penalty
Summary
A failure occurred in the facility when laboratory tests were obtained for a resident without a physician order. The resident, who was readmitted with an abdominal hematoma and had moderate cognitive impairment, was supposed to have CBCs performed every two weeks to monitor her condition, as discussed between the unit manager and the nurse practitioner. However, review of the electronic medical record revealed that no physician orders for these CBCs were entered, even though the laboratory tests were performed as scheduled. Interviews with facility staff indicated that there was confusion regarding responsibility for entering orders into the electronic system, with the nurse practitioner stating she did not have access to enter orders and the unit manager and DON indicating that nurses are responsible if providers do not enter them. Additionally, the facility did not have a policy on laboratory services. This lack of a documented physician order prior to obtaining laboratory tests had the potential to result in unnecessary laboratory testing for residents.
Failure to Collaborate and Document Hospice Services
Penalty
Summary
The facility failed to collaborate care with the hospice agency for a resident who was receiving hospice services. The resident, who had chronic obstructive pulmonary disease and dementia with severe cognitive impairment, was readmitted to the facility and had a care plan indicating a terminal prognosis and the need for hospice services. The hospice plan of care specified that the resident was to receive visits from a skilled nurse and a home hospice aide twice a week. However, documentation in the hospice binder showed missing records for skilled nurse visits during two separate weeks and incomplete documentation for home hospice aide visits, with some weeks lacking evidence of the required two visits. Interviews with staff revealed that the LPN believed the aide and nurse each visited once a week unless there was a change in condition, at which point additional visits would be requested. The DON stated that the unit manager was responsible for obtaining hospice visit documentation but acknowledged that supporting documentation for the visits was not available, despite the belief that visits had occurred. The administrator was unable to provide a copy of the hospice contract during the survey, as it could not be located and the hospice agency was unavailable after hours.
Infection Control Failures in PPE Use, Medication Handling, and Policy Review
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols in several instances. One incident involved a staff member, the Director of Maintenance, entering a contact isolation room of a resident diagnosed with Clostridium difficile (C. Diff) without donning the required personal protective equipment (PPE). The staff member touched surfaces within the room, including the overbed table and the footboard of the resident's bed, with bare hands. The staff member later acknowledged not noticing the contact isolation signage and not wearing PPE as required. Facility policy specifies that staff must wear gloves and gowns when entering rooms under contact precautions, particularly for infections such as C. Diff. Another deficiency was observed during medication administration, where a registered nurse poured oral medications directly into her bare hands before placing them into a medicine cup and handing them to a resident. The nurse admitted to sanitizing her hands beforehand but recognized that medications should not be handled with bare hands. Facility policy requires that medications be dispensed without direct hand contact. Additionally, the facility failed to review and/or revise key infection control policies, such as those related to antibiotic stewardship and transmission-based precautions, on an annual basis as required by their own protocols.
Failure to Accurately Reflect Resident Code Status in EMR
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately reflected in the electronic medical record (EMR). Upon admission, the resident, who had diagnoses including depression, anxiety, and bipolar disorder and demonstrated intact cognition, signed a form electing Do Not Resuscitate (DNR) status. However, the EMR Profile tab and a physician's order both incorrectly indicated that the resident was to receive cardiopulmonary resuscitation (CPR), designating her as Full Code. Multiple staff interviews confirmed the discrepancy between the resident's documented wishes and the information in the EMR. The admitting nurse completed the Code Status Form with the resident, who clearly expressed a desire for no CPR, and the resident wore a DNR bracelet. Despite this, the order for CPR was entered into the EMR, and staff were unaware of the inconsistency. The Director of Nursing acknowledged that the process for verifying code status orders was not consistently followed, as staff were expected to refer to the completed Code Status Form and double-check the information entered into the EMR. The facility's policy required clear documentation of advance directives in designated sections of the medical record, but this was not adhered to in this instance.
Failure to Notify Ombudsman and Provide Proper Bed Hold/Transfer Notice
Penalty
Summary
The facility failed to notify the ombudsman of resident discharges and did not provide a transfer notice and bed hold policy to the resident and/or resident representative for one of three residents reviewed for discharges. Specifically, for a resident admitted with thrombocytopenia and anemia, who was cognitively intact, the documentation related to their transfer to the hospital for gastrointestinal bleeding was incomplete. The Bed Hold/Transfer Notice form was not properly filled out, lacking details about the reason and destination for the transfer, and was not signed by the resident, only by the nurse. There was also no evidence that the resident or their representative received a copy of the notice. Interviews with facility staff revealed that ombudsman notifications for discharges were missing for the months of July and August, with only September notifications available. The Director of Nursing and Social Worker confirmed the absence of required notifications, attributing it to staffing vacancies. The facility's policy requires that a signed and dated copy of the bed-hold notice be provided to the resident or representative and kept in the medical record, but this was not followed in the reviewed case.
Failure to Develop and Implement Behavioral Health Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented to address the behavioral health needs of a resident with diagnoses including fibromyalgia, morbid obesity, and depression. Although the resident demonstrated intact cognition and did not initially exhibit mood or behavioral symptoms upon admission, subsequent interviews and record reviews revealed multiple incidents of behavioral issues. These included the resident making accusatory statements, threatening staff, requesting not to work with certain CNAs, and engaging in loud, aggressive interactions with staff and family members in the facility lobby. Staff members, including the DON, Unit Manager, and Social Worker, acknowledged awareness of these behaviors but confirmed that no specific behavioral interventions or care plan addressing these issues had been put in place. Despite facility policies requiring the assessment and care planning of behavioral health needs, the care plan for this resident did not reflect her behavioral symptoms or outline measurable interventions. Staff responses to the resident's behaviors were informal and inconsistent, such as having another staff member present during interactions or reassigning CNAs, rather than being part of a documented, individualized care plan. The lack of a formalized care plan addressing the resident's behavioral health needs constituted a deficiency in meeting regulatory requirements for comprehensive, person-centered care planning.
Failure to Address Significant Weight Loss in Resident with Complex Medical Needs
Penalty
Summary
A significant deficiency occurred when the facility failed to address a 19% weight loss in one month for a resident with multiple complex medical conditions, including Parkinson's disease, dementia, diabetes, dysphagia, and several advanced pressure ulcers. The resident was admitted and re-admitted to the facility, and her care plan identified her as being at nutritional risk due to wound infection, dysphagia, and increased nutritional needs for wound healing. Despite these risks and a documented significant weight loss, the care plan was only revised to note the weight loss, without adding new or revised interventions to address the issue. The resident's weight dropped from 154.1 lbs to 124 lbs over a one-month period, as confirmed by multiple re-weighs. The care plan approaches included monitoring for signs of malnutrition and significant weight loss, providing supplements, and ensuring total assistance with feeding. However, when the significant weight loss was identified, neither the physician nor the registered dietician implemented new interventions. The registered dietician acknowledged the weight loss and stated that no additional measures were put in place, citing limited options and the absence of a fortified foods program. The director of nursing was unaware of the weight loss and stated that she would have expected new interventions to be implemented. Throughout this period, the resident continued to receive the same supplements and assistance with feeding, and her oral intake was documented as adequate. Despite this, the significant weight loss was not addressed with additional interventions, and the facility's policy requiring action in response to significant weight changes was not followed. The deficiency was identified through interviews, record reviews, and policy review, which confirmed that the facility failed to take appropriate action to maintain the resident's nutritional status.
Improper Storage of Nebulizer Mask Breaches Infection Control
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease (COPD) was observed to have their nebulizer mask stored improperly. The resident, who was moderately cognitively impaired, had a physician's order for Ipratropium-Albuterol inhalation solution to be administered via nebulizer as needed for shortness of breath or cough. During two separate observations, the nebulizer mask was found lying uncovered on the bedside table, rather than being stored in a plastic or Ziploc bag as required by facility policy and infection control guidelines. Staff interviews confirmed that the mask should have been stored in a plastic bag when not in use. The registered nurse, unit manager, and infection preventionist all acknowledged that the observed storage method did not comply with the facility's policy, which specifically directs that nebulizer masks and mouthpieces be stored in a Ziploc bag. This failure to follow proper storage procedures for respiratory equipment constituted a breach of infection control practices.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 879 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oak Creek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Ridge Health Services | 3.2 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Greenfield | 3.3 mi | ★★★★★ | 5 | 1 |
| Greendale Park Nursing And Rehab | 4.3 mi | ★★★★★ | 42 | 0 |
| Chi Franciscan Villa | 4.4 mi | ★★★★★ | 33 | 0 |
| Willowcrest Health Services | 4.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.