Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Middleton Village Nursing And Rehab during CMS and state inspections, most recent first.
Food was not consistently served at safe, appetizing temperatures and was often described by residents as cold, bland, or tough to chew. A test tray showed hot items served cold, including a pork chop, rice, and spinach at low temperatures, and multiple residents reported meals arriving cold, sitting in the hallway on large trays, and not being palatable. The DM and NHA acknowledged that hot foods should be served hot and cold foods served cold.
Unsafe Food Handling During Meal Prep: A dietary aide washed hands, put on gloves, touched the counter, lunch tickets, and the tray cart, then directly handled pork chops with the same gloves during meal service. The DM stated staff should use tongs or clean gloves and that staff should wash hands and put on a clean pair of gloves before directly handling food.
The facility assessment did not include staffing levels needed for specific shifts. The assessment stated it was used to determine resources needed for competent resident care and staffing was based on acuity and ADL index scores, but it did not identify shift-specific staffing levels. During interview, the NHA said assessment reviews occur yearly and as needed, and that she needed to review policies and procedures when asked whether shift staffing levels should be included. Staff also reported the facility did not have a facility assessment policy.
Cold water in 3 shower rooms prevented residents from receiving comfortable showers. Residents with BIMS scores ranging from cognitively intact to impaired reported refusing showers or enduring cold water, and one resident had not showered in months because staff said there was no hot water. Surveyor checks found shower water temperatures well below adequate hot levels, while maintenance logs reflected checks in resident rooms only, not the shower rooms. Staff and the NHA acknowledged ongoing complaints about the cold water.
Failure to Provide Scheduled ADL Hygiene Services: Several residents did not receive scheduled showers, and some refused bathing because shower water was cold or there was no hot water. CNAs and a hospice nurse reported the shower room water had been cold for weeks, while documentation showed missed shower/bath entries, bed baths in place of showers, and incomplete grooming care such as shaving and hair washing for residents who were cognitively intact and dependent on staff for ADLs.
Medication storage was deficient when surveyors found multiple unlabeled or improperly labeled meds on several med carts. An RN and ADON observed an open insulin pen, GLP-1 pens without resident identifiers, an inhaler with an illegible open date, and open, undated ophthalmic solution, inhaler, and insulin pen items. The DON stated open meds should be dated and dates should be legible.
A resident with moderate cognitive impairment and diagnoses including traumatic hemothorax, rib fractures, paranoid schizophrenia, and CHF preferred Spanish and needed an interpreter to communicate with staff. He told the surveyor he had trouble communicating and only spoke a little English, while observations showed he relied on hand signals. Records, the care plan, and CNA Kardex all identified a language barrier and use of translation services, but staff interviews showed inconsistent use of interpreters and some assessments were completed without a Spanish translator.
A resident with a CPR code status and intact cognition had no advance directive in the chart and no documented discussion of advance care planning beyond code status. The resident stated she had never spoken with anyone about advance directives, while the SSD later could not find documentation of care conferences or advance directive discussions, and the NHA said she would expect such documentation.
Failure to Document Resident Transfer Incident and Fracture in Medical Record: A resident with diabetes, anemia with CKD, osteoporosis, and hemarthrosis reported that during a wheelchair-to-bed transfer her leg got caught in the wheelchair, followed by significant pain and a later hospital transfer for a right tibial plateau fracture. The chart contained notes about pain, acetaminophen, ice, and contacting the POA, but no documentation of the transfer incident or post-event monitoring in the medical record; the DON said risk management paperwork was completed separately.
A resident receiving hospice care with ESRD, DM2, an indwelling catheter, and moderate cognitive impairment did not have hospice collaboration and communication processes established to ensure continuity of care. Surveyors found no hospice binder and no hospice notes in the facility EMR; hospice notes were only available from an outside EMR printout. RN and LPN staff said they would look in the EMR or hospice binder and did not have access to the outside EMR, while the DON said hospice notes were emailed to clinical management, with some important information faxed to the facility.
A facility did not report an allegation of sexual abuse involving a resident and a CNA to the state agency within the required timeframe. Although the incident was investigated internally and staff were educated on the abuse policy, the mandated report was not submitted as required by facility policy.
A resident's family member elevated a grievance to an allegation of sexual abuse by a CNA, but the facility did not conduct a thorough investigation or report the findings to the state agency within the required timeframe. The CNA continued working during the investigation, and the facility did not follow its abuse policy for immediate protection and timely reporting.
Surveyors found that food preparation, storage, and serving areas were not maintained in a clean and sanitary manner, with dirty meal trays left in the dining room, non-functional hand sanitizer dispensers, cluttered and unclean dish room surfaces, an unclean microwave, uncovered and undated butter, and stained walls and curtains. Dietary staff and management confirmed these practices did not follow facility policies.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with a kitchen door left detached for months, meal trays left in resident rooms after meals, and shower rooms observed to be cluttered, unclean, and in disrepair. Staff and management were aware of these issues, and residents expressed discomfort with the conditions.
The facility did not report two separate allegations of abuse—one involving an alleged sexual abuse and another involving a verbal threat—within the required timeframe to the State Agency or law enforcement, despite both incidents being recognized by staff and administration as reportable under facility policy.
A resident reported that another resident made a threatening statement, which was disclosed to therapy staff and subsequently reported to the NHA. The facility's investigation was incomplete, lacking interviews with involved staff and other residents, and missing key documentation. The NHA acknowledged the investigation was not thorough, as required.
A resident with multiple neurological and psychiatric diagnoses did not have consistent or documented checks of their elopement device's function. Staff interviews revealed confusion and inconsistency regarding how and how often to check the device, with some staff unaware of the correct procedure or equipment. The facility's policy did not address functional monitoring of the device, resulting in inadequate supervision to prevent accidents.
A resident with multiple medical conditions did not have two doses of thyroid medication documented as administered, with blank entries on the MAR. Staff interviews revealed inconsistent understanding of documentation procedures, and facility policy requiring proper documentation was not followed, resulting in an inability to verify if the medication was given.
The facility failed to provide necessary care for residents, resulting in harm and potential harm. A resident with a tooth abscess did not receive timely antibiotics, leading to increased pain and infection. Another resident's breast blisters were not properly assessed or treated, worsening the condition. Additional issues included inadequate care planning for a resident on chemotherapy and incomplete wound care documentation. These deficiencies highlight lapses in care, communication, and documentation.
A resident developed a stage 3 pressure injury due to inadequate care and prevention measures. The facility delayed providing an appropriate mattress and failed to perform wound care per physician orders. Observations showed the resident lying directly on the wound and with heels in contact with the mattress. Documentation and communication regarding the wound were insufficient, with missing measurements and descriptions in the medical record.
A resident experienced severe breakthrough pain due to the facility staff's failure to administer prescribed PRN pain medication for five hours, despite its availability in contingency stock. The resident, who was cognitively intact and had a history of serious health conditions, reported a pain level of 9 out of 10. The facility's pain management policy was not followed, as there was a lack of timely response and documentation of non-pharmacological interventions. Communication gaps and procedural failures among staff contributed to the deficiency.
The facility failed to maintain food safety standards, with moldy food found in a resident's room and improperly labeled food items in the kitchen. A resident stored perishable food at room temperature, and housekeeping staff had previously reported moldy food to nursing staff, but the DON was unaware. Additionally, an ice scoop was improperly stored inside the ice machine, posing a cross-contamination risk.
The facility did not ensure proper disposal of garbage and refuse, potentially affecting all 75 residents. Surveyors observed the main dumpster with its lid open and various items improperly discarded on the ground, including surgical masks, condiment packets, used disposable gloves, and scattered cardboard. The Dietary Manager acknowledged the issue and stated it would be addressed immediately.
The facility failed to conduct timely and thorough background checks for a Medication Technician and two CNAs, as required by their policies. The checks were either outdated or incomplete, lacking necessary documentation such as Wisconsin results and unanswered BID questions. Interviews confirmed that these checks should occur every four years, but this was not followed.
A resident was administered psychotropic and antipsychotic medications without an appropriate diagnosis or proper informed consent. Verbal consent was obtained but not followed by signatures, contrary to facility policy. Staff interviews confirmed the lack of adherence to policy and regulatory guidance.
A medication error rate of 7.69% was identified in a facility, exceeding the acceptable 5% threshold. An LPN administered an incorrect dose of calcium carbonate and omitted Pyridoxine HCl for a resident, citing a likely transcription error and unavailability in contingency stock. The DON confirmed that medications should follow physician orders.
A resident with limited mobility was not walked according to their care plan, which required ambulation assistance twice daily. Despite the resident's cognitive intactness and medical conditions, facility documentation showed multiple days without walking, and no refusals were recorded. Interviews with staff revealed inconsistencies in following the walking program, with some staff unaware of refusals and others not prompting the resident to walk.
A CNA in a long-term care facility failed to follow proper infection control procedures by not changing gloves or washing hands after assisting a resident and before handling clean linens. Additionally, a resident's room was found with soiled linens on the floor and a strong odor of urine, highlighting a breach in maintaining a sanitary environment.
The facility failed to implement an effective emergency training program, leaving staff unprepared for a severe weather event and power outage. Staff were unable to identify emergency outlets and had not received training on handling such emergencies, leading to a chaotic response and difficulties in providing necessary care to residents.
A resident with dysphagia, aphasia, and intellectual disability had two conflicting enteral feeding orders being signed out as administered, and the feeding bottle lacked proper labeling. The facility policy was not followed, leading to potential risk for the resident's care.
The facility failed to obtain and transcribe CPAP orders upon admission for two residents with obstructive sleep apnea. One resident's CPAP order was delayed by over two years, while another went 43 days without the necessary order, leading to an emergency room visit during a power outage. The DON confirmed that CPAP orders should have been present from admission.
The facility failed to report an incident of verbal abuse involving a resident with moderate cognitive impairment. Despite a CNA reporting the abuse, the Director of Nursing and the Nursing Home Administrator were unaware of the incident and did not report it to the necessary authorities as required by policy.
A facility failed to investigate and report an allegation of verbal abuse involving a resident with moderate cognitive impairment. Despite the incident being reported by a CNA, the facility did not follow its policy to investigate and report the incident to the state agency.
The facility failed to ensure that three residents received scheduled showers, leading to concerns about personal hygiene. Residents reported missed showers due to staff shortages and incorrect documentation of refusals. The Director of Nursing confirmed that scheduled showers were not completed or properly documented.
The facility failed to provide adequate care and monitoring for three residents. One resident with a history of aspiration pneumonia was not properly care planned or assessed despite non-compliance with dietary recommendations. Another resident experienced episodes of constipation due to inadequate monitoring of bowel movements and unmet dietary needs. A third resident did not receive wound care as ordered, with lapses in documentation and treatment.
A resident with Type 2 Diabetes Mellitus was admitted with orders for POCT glucose testing four times daily, but the facility failed to monitor the resident's blood glucose levels. The resident's MAR did not include the glucose monitoring order, and the DON confirmed that the monitoring was not conducted as required.
A resident with multiple diagnoses did not receive her prescribed doses of amlodipine, ezetimibe, and carbamazepine. The facility's policies require timely administration and documentation of medications, but the medications were not given, and no explanation was documented. Interviews with staff confirmed the process for obtaining unavailable medications, but the medications were still not administered as ordered.
A resident with a history of cerebral infarction, dementia, and mobility issues eloped twice despite wearing a WanderGuard device and being identified as an elopement risk. During the second incident, staff did not respond promptly to the alarm, reset it without verifying the resident's location, and delayed notifying law enforcement. The resident was later found 1.5 miles away. The facility's policies lacked specific guidance on timely law enforcement notification and ensuring door alarms remain active until the resident is located, contributing to the Immediate Jeopardy finding.
A resident, who was cognitively intact, reported feeling violated when an LPN physically grabbed their arm and removed a dab/vape pen from their hand. The incident was corroborated by multiple staff members, but the DON did not initially report or investigate it until later informed. The facility's policy mandates protections against such actions.
A resident with multiple sclerosis, bipolar disorder, and anxiety disorder alleged that an LPN physically grabbed his arm and removed a dab/vape pen from his hand. Despite the facility's policy requiring immediate reporting of such incidents, the Director of Nursing did not report the allegation to the State Agency until several days later, after becoming fully aware of the resident's claims.
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident and an LPN. The incident involved the LPN allegedly grabbing the resident's arm and forcibly removing a dab/vape pen from the resident's hand. Conflicting accounts from staff and the resident were not promptly investigated, leading to a deficiency in protecting the resident from potential abuse.
A facility failed to ensure a resident was using a CPAP machine as ordered by the physician. The resident, who was cognitively intact, confirmed the absence of the CPAP machine. An LPN and the DON acknowledged that the machine was not available and the physician was not notified.
Food Served at Improper Temperatures and Not Palatable
Penalty
Summary
The facility did not ensure that residents received food and drink that were palatable and at a safe and appetizing temperature. During observation, interview, and record review, surveyors found that residents on all 5 hallways voiced concerns about food temperatures and the palatability of meals served. A test tray received by the surveyor showed hot foods served cold, including a pork chop at 120 F, rice at 123.9 F, and spinach at 128 F, and the pork chop was described as chewy and not palatable. Multiple residents reported that meals were frequently cold, bland, tough to chew, or otherwise unappetizing. One resident stated hot foods were served cold and that requested menu items were not always received; when followed up at lunch, the pork chop was cold and difficult to eat. Other residents stated the food was cold all the time, served on big trays that sat in the hallway, never at the right temperature, bland, terrible, and not palatable at all. The Dietary Manager and Nursing Home Administrator both stated that hot foods should be served hot and cold foods served cold.
Unsafe Food Handling During Meal Preparation
Penalty
Summary
The facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. During observation of lunch meal preparation, a dietary aide washed hands, put on gloves, touched the counter, lunch tickets, and the tray cart, and then directly touched pork chops while wearing the same gloves. The dietary aide stated that clean gloves should have been worn when handling food. The facility policy stated that food service employees must follow safe food handling practices, that bare hand contact with food is prohibited, and that gloves must be changed between tasks. The Dietary Manager stated that staff should use tongs or clean gloves when handling food and that staff should wash hands, put on a clean pair of gloves, and then directly handle food. The Nursing Home Administrator indicated understanding of the concern.
Facility Assessment Missing Shift Staffing Levels
Penalty
Summary
The facility-wide assessment did not include information on staffing levels needed for specific shifts. The assessment, last updated 2/26/26, stated that its purpose was to determine what resources were necessary to care for residents competently during day-to-day operations and emergencies, and that staffing was to be evaluated based on resident acuity and ADL index scores. However, the assessment did not identify staffing levels needed for specific shifts, and the surveyor noted this omission during review as part of a resident investigation. During interview on 3/5/26, the NHA stated that facility assessment reviews occur yearly with additional reviews when needed and that concerns or changes can be identified by any staff member and brought to the IDT for review. When asked whether staffing levels for each shift should be included in the facility assessment, the NHA said she needed to review policies and procedures and would let the surveyor know. Survey staff also reported that the facility did not have a facility assessment policy. The listed reviewers for the assessment included the NHA, DON, a Governing Body representative from the corporate organization, and the facility Medical Director.
Cold shower water in multiple resident shower rooms
Penalty
Summary
The facility did not ensure that 3 of 3 shower rooms in use provided adequate hot water, affecting residents who used those rooms, including R3, R51, and R58. The deficiency was identified through observation, interview, and record review and involved the resident right to a safe, clean, comfortable, and homelike environment, including safe support for daily living. The facility policy on water temperatures required maintenance staff to check thermostats and temperature controls and to record periodic tap water temperature checks in a safety log. R3, who was admitted with diagnoses including morbid obesity, limited activity due to disability, reduced mobility, and muscle weakness, and whose BIMS score was 15, stated he was supposed to shower twice weekly but sometimes refused because the facility ran out of hot water. R51, admitted with multiple sclerosis and need for assistance with personal care, and whose BIMS score was 12, stated the shower water was on the colder side and became colder later in the day, requiring her to grit her teeth during rinsing. R58, admitted with diabetes type 2 and arthritis, and whose BIMS score was 14, stated she had not showered in at least 3 months because staff told her there was no hot water and asked whether she wanted a shower. The facility also had grievance forms documenting resident and staff complaints about cold shower-room water, including a grievance stating there were several complaints about cold water in the shower room. Maintenance staff reported checking water temperatures in resident rooms but not in shower rooms, and the temperature logs reviewed were from resident rooms only. Surveyor observations of the three shower rooms found water temperatures of 91.2, 78.9, and 84.3 degrees Fahrenheit after running full hot water for 5 minutes, with the water feeling colder and fluctuating down to 78.9 degrees. The maintenance staff, CNA, and NHA all acknowledged ongoing concerns about cold shower water, and the NHA stated the facility had been aware of the issue since 2/5/26 and had obtained plumber estimates while trying to determine what needed to be fixed.
Failure to Provide Scheduled ADL Hygiene Services
Penalty
Summary
The facility did not ensure that residents who were unable to complete ADLs received the necessary services to maintain bathing, grooming, personal hygiene, and oral hygiene. The deficiency involved 5 of 23 sampled residents: R3, R14, R29, R48, and R58. The facility policy stated that, based on the comprehensive assessment and resident needs and choices, the facility provides necessary care and services for hygiene, mobility, elimination, and dining, and monitors and evaluates the resident’s response to care plan interventions and treatment. R3, who was cognitively intact and had diagnoses including morbid obesity, reduced mobility, and muscle weakness, stated he was supposed to receive showers twice weekly but sometimes refused because the water was too cold or there was no hot water. His February CNA documentation showed no showers for the month, with only one bed bath documented. R58, who was cognitively intact and had diagnoses including diabetes type 2 and arthritis, stated she had not showered in at least 3 months because staff told her there was no hot water and asked whether she wanted a shower; her February documentation showed no showers and three bed baths. CNA and hospice staff reported the shower room water had been cold for weeks and that the issue had been reported to maintenance. R29, R14, and R48 also did not receive showers as scheduled. R29 stated her shower was cold, and documentation showed missed shower/bath documentation on some scheduled days. R14’s records showed multiple scheduled shower dates with no shower/bath documentation on several of those dates. R48 had scheduled showers, but documentation showed missed shower/bath entries and bed baths instead; she also had long facial hair still present and stated she had not been washed properly during bed baths and that her hair was not being washed. DON B stated she was not aware residents were refusing showers because of cold water and acknowledged that shaving and nail care are part of ADLs and should be offered and provided as part of the ADL routine.
Medication Storage Lacked Required Labels and Open Dates
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles on 3 of 3 medication carts reviewed. On the Harbor Hall medication cart, surveyors found an undated open Humalog insulin pen for R36 and a box of 3 warm Mounjaro GLP-1 pens that did not have resident identifiers fixed to the box or the pens. The facility policy stated that drug containers with missing, incomplete, improper, or incorrect labels must be returned to the pharmacy before storage, and that discontinued, outdated, or deteriorated drugs must not be used. On the St. [NAME] Hall medication cart, surveyors found an inhaler for R67 with an illegible open date. On the Depot Hall medication cart, surveyors found an open, undated ketorolac ophthalmic solution for R62, an open, undated Advair inhaler for R17, and an open, undated Lispro insulin pen for R19. During interview, RN P stated the inhaler date could not be read, and ADON O and DON B stated that medications such as inhalers, ophthalmic solutions, and insulin pens should be dated when opened and that open dates should be legible.
Failure to Provide Communication in Resident’s Preferred Language
Penalty
Summary
The facility did not ensure that a resident with limited English proficiency was fully informed in a language he could understand about his health status, care, and treatments. The resident was admitted with diagnoses including traumatic hemothorax, multiple left rib fractures, paranoid schizophrenia, chronic diastolic CHF, anxiety disorder, and a developmental disorder of scholastic skills. His MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and identified Spanish as his preferred language with a need for an interpreter to communicate with health care staff. During interview, the resident stated he had trouble communicating with staff and wanted them to speak Spanish, and he said he only spoke a little English. The surveyor observed him using hand signals and having word-finding difficulty. Facility records also documented that Spanish was his primary language and that he needed or wanted an interpreter. His care plan and CNA Kardex both identified a communication problem related to a language barrier and directed staff to utilize translation services, and a progress note also stated that he needed or wanted an interpreter. Despite this, staff interviews showed inconsistent communication practices. A CNA stated the resident spoke very little English and often relied on his sister to translate. An LPN stated the resident did not speak English and mostly pointed to communicate, while also saying the translator line was only used for more extensive communication. Therapy staff said the resident could speak broken English and answer basic yes-or-no questions, and one therapist completed the resident’s initial evaluation without a Spanish translator and without the sister present. The DON stated the resident could communicate basic needs and understand English, but also acknowledged that staff should use the language line for more extensive conversation. The facility had a translator app sign posted in the resident’s room area, but the report states the facility did not ensure he received communication in his preferred language or a language he was able to understand.
Advance Directive Discussion Not Documented
Penalty
Summary
The facility did not ensure that a resident’s right to formulate an advance directive was addressed for 1 of 23 sampled residents, R76. R76 was admitted with a current code status of CPR and had a BIMS score of 14, indicating she was cognitively intact. Her medical chart contained code status paperwork, but no advance directive was present, and no documentation was found showing discussions about advance care planning beyond code status. During interview, R76 stated she had never talked with anyone regarding advance directives and said she wanted to see a social worker, but no one ever came. She also stated she had a care conference with therapy but never discussed advance directives. The Social Services Director stated care conferences were held as often as possible and that code status, POA, and other care topics were discussed, but later could not find any documentation of care conferences or advance directive discussions and stated she had not talked with R76. The Nursing Home Administrator stated she would expect documentation of such discussions.
Failure to Document Resident Transfer Incident and Fracture in Medical Record
Penalty
Summary
The facility did not maintain complete and accurately documented medical records for one resident, R18, after an incident involving a transfer and a subsequent fracture. R18 was admitted with diagnoses including Type II diabetes, anemia with chronic kidney disease, age-related osteoporosis, and hemarthrosis of the right knee. During interview, R18 stated that on 2/6/26 she was being transferred from her wheelchair to the bed when her leg got caught in the wheelchair. She reported that she did not fall, but that she had a lot of pain and could not get staff to send her to the emergency room. Surveyor review of the medical record found no documentation of the incident in which R18’s leg became caught between the wheelchair and the bed, and no documentation of monitoring after the event within the medical record. The first related progress note was dated 2/7/26 and documented that R18 complained of right knee pain, repeatedly used the call light, and wanted to go to the hospital; she was given acetaminophen and an ice pack. The next note documented that her son, who was her POA, was contacted and later gave permission for her to go to the hospital, where she returned with a diagnosis of a right tibial plateau fracture. The DON stated the facility completed risk management paperwork, but that document was not part of the medical record.
Hospice Notes Not Available to Direct Care Nursing Staff
Penalty
Summary
The facility did not ensure hospice collaboration and communication processes were established to maintain continuity of care between hospice and the facility for one resident receiving hospice services. The resident was admitted with diagnoses including end stage renal disease, type 2 diabetes mellitus, infection and inflammatory reaction due to an indwelling urethral catheter, obstructive and reflux uropathy, and urinary retention. The resident's MDS indicated moderate cognitive impairment, an indwelling catheter, and hospice care. The physician orders included hospice services for end stage renal disease, and the care plan addressed coordination between hospice and the facility for symptom management, skin integrity, nutrition and hydration, psychosocial support, and notification of changes in condition. During survey review, no hospice binder could be located for the resident, and no hospice notes were found in the facility's electronic medical record. When requested, the facility provided hospice notes printed from an outside electronic medical record, dated the day they were printed. Interviews with RN and LPN staff showed they would look in the facility EMR or hospice binder for hospice notes and did not have access to the outside electronic medical record. The DON stated hospice nurses sent notes by email to the clinical management team, that hospice providers also gave in-person reports, and that important information was faxed to the facility, while direct care licensed nursing staff did not have access to the outside electronic medical record.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the appropriate authorities within the required timeframes. Specifically, an allegation of sexual abuse was made by a family member, who reported to the Nursing Home Administrator (NHA) that a CNA had inappropriately touched a resident's private area during routine care. The facility became aware of this allegation on 9/23/25 and conducted an internal investigation, including staff interviews and education on the abuse policy, which concluded on 9/30/25. Despite the facility's policy requiring immediate reporting of such allegations to the state agency, the incident was not reported as required. As of 10/8/25, a report had still not been submitted to the state agency. During an interview on 10/8/25, the NHA acknowledged that the incident should have been reported to the state agency on the day the allegation was made, in accordance with the facility's abuse policy and the education she had received.
Failure to Investigate and Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of sexual abuse involving a resident. A family member initially raised a concern regarding peri care performed by a CNA without gloves, which was documented as a grievance. This concern was later elevated to an allegation of inappropriate touching of the resident's vaginal area by the same CNA. Despite the escalation to a sexual abuse allegation, the facility did not conduct additional interviews or expand the investigation, and the CNA continued to work with residents during the investigation period. The facility's abuse policy requires immediate protection of the alleged victim, thorough investigation, and timely reporting to the state agency, but these steps were not fully followed. Furthermore, the facility did not submit the required report of the investigation's findings to the state survey agency within the mandated five working days. Documentation shows that the CNA remained on duty after the allegation was made, and education on abuse policies was not completed until several days later. The administrator acknowledged that the incident should have been reported to the state agency when the allegation was elevated, but this was not done in accordance with facility policy and state law.
Failure to Maintain Sanitary Food Preparation and Storage Practices
Penalty
Summary
The facility failed to ensure the preparation, storage, and serving of food in a clean and sanitary environment, as evidenced by multiple observations during the survey. Partially eaten meal trays from a previous meal were left on tables in the dining room while residents were eating breakfast. Three wall-mounted hand sanitizer dispensers in the dining room were found to be non-functional. In the dish room, a table was cluttered with stacked cardboard boxes, a tray of glasses, a dirty towel, dirty coffee pots, a fleece jacket, and a metal pot inside a box of aprons, all in violation of facility policy regarding food storage and cleanliness. Additionally, the inside of the kitchen microwave was observed to be covered with dried, multi-colored splatters, indicating it had not been cleaned as required by the facility's cleaning schedule. Further observations included an opened package of butter left uncovered and undated on a cart by the stove, and multi-colored stains on the walls near the dish room entrance and on a curtain by the garbage in the dining room. Interviews with dietary staff and the dietary manager confirmed that these cleaning and storage practices did not align with facility policies, which require all foods to be stored covered, labeled, and dated, and for storage areas to be kept neat and clean. The dietary manager acknowledged the deficiencies and indicated awareness of the required procedures.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to provide a safe, clean, comfortable, and homelike environment for residents, as required by policy. In the kitchen, a door connecting the dish room and main dining room was found detached from its hinges and leaning against the kitchen sink for an extended period. Staff interviews and email records revealed that the issue had been ongoing for several months, with maintenance and management aware of the problem but unable to resolve it due to delays in ordering a replacement door. The lack of a functioning door raised concerns about sanitation and potential cross-contamination between the kitchen and dining areas. In resident rooms, meal trays were observed left unattended after residents had finished eating and left the room. Interviews with staff indicated that tray removal was based on resident preference, but at least one resident expressed discomfort with trays being left in her room. This practice did not align with maintaining a clean and homelike environment for residents. The facility's shower rooms were found to be cluttered, unclean, and not homelike. Observations included multiple lifts and shower chairs stacked in the rooms, unlabeled and open bottles of skin and hair cleanser, dust, stained items, and personal belongings left out. In one shower room, a ceiling tile was dripping water, and the shower was not fully functional, with a missing handle and water leaking from the area. Staff interviews confirmed awareness of these issues, and both the DON and NHA agreed that the shower rooms were neither clean nor homelike. Additional observations in another shower room included a dirty toilet, a commode bucket with dried residue, lack of hand sanitizer, and soiled towels and sponges left out.
Failure to Timely Report Alleged Abuse and Threats
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, as required by policy. In one instance, a resident's Power of Attorney (POA) reported an alleged sexual abuse incident involving a staff member, but the facility did not report this allegation to the State Agency or law enforcement, despite the administrator acknowledging that the allegation met the definition of sexual abuse and was a reportable incident. Documentation showed that the concern was initially treated as a grievance, and while an internal investigation was conducted, the required external reporting did not occur. In another case, a cognitively intact resident reported to therapy staff that another resident made a threatening statement, which was recognized by staff and administration as verbal abuse and a reportable incident. However, this allegation was also not reported to the State Agency within the required timeframe. The facility's own policy defined such statements as verbal abuse and required immediate reporting, but the incident was only documented as a grievance without evidence of timely external notification.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
A cognitively intact resident (R5), as indicated by a BIMS score of 13, reported that another resident (R9) made a threatening statement to her, saying, "If I had a gun, I'd shoot you." R5 did not report the incident immediately but disclosed it during a therapy session the following day to an occupational therapist (OT K), who stated she would report it to the nursing home administrator (NHA A). Both OT K and a physical therapist (PT L), who was present during the disclosure, confirmed they were not interviewed or asked to provide statements regarding the incident. The facility's investigation was limited to a grievance form that lacked critical details, such as the name of the resident who made the comment, the staff who reported the allegation, and documentation of interviews with staff or other residents. The NHA acknowledged that the incident was considered an allegation of abuse and that the investigation process was initiated. However, the investigation did not include interviews with other staff or residents to determine if similar threats had been made by R9 to others. The only actions taken were speaking with R9, who denied intent and acknowledged the inappropriateness of the comment, and searching R9's room. The NHA admitted that the investigation was not thorough, as required by facility policy and regulatory expectations.
Failure to Ensure Consistent Monitoring of Elopement Device Function
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, specifically regarding the monitoring of an elopement device. The resident in question had multiple diagnoses, including cerebral infarction, intracerebral hemorrhage, psychosis, mood disorder, substance abuse, anxiety disorder, personality disorder, and encephalopathy. Although there was a physician's order to check the placement and location of the wander device, there was no order or documentation in the treatment authorization request (TAR) to check the function of the device. The facility's Elopement/Unsafe Wandering Policy and Procedure did not address monitoring the function of the elopement device. Interviews with nursing staff and facility leadership revealed inconsistent knowledge and practices regarding how and how often to check the function of the wander device. Some staff were unaware of the correct procedure or equipment to use, while others provided varying answers about the frequency of checks, ranging from every shift to daily or only on the night shift. The Director of Nursing stated that all nurses should know how to check the function of the device and that it should be done every shift, but this was not reflected in staff responses or in facility policy. This lack of clear guidance and consistent practice led to the deficiency in ensuring the resident's safety from accident hazards.
Failure to Document and Verify Medication Administration
Penalty
Summary
The facility failed to ensure the provision of pharmaceutical services that meet the needs of each resident, specifically in the accurate administration and documentation of medications. For one resident with multiple diagnoses, including hypothyroidism, the Medication Administration Record (MAR) showed two blank entries for scheduled doses of levothyroxine, a thyroid medication. Facility policy requires that medications be administered as ordered and that the MAR be initialed after each administration. However, on two separate dates, there was no documentation to confirm whether the medication was given. Interviews with facility staff, including the Director of Nursing, Infection Preventionist, and several LPNs, revealed uncertainty and inconsistency regarding the meaning of blank boxes on the MAR. Staff responses indicated that a blank could mean the medication was not given, not documented, or simply not checked off, and there was no way to verify administration in these instances. The lack of documentation and clarity among staff led to the inability to confirm that the resident received their prescribed medication as ordered.
Deficiencies in Resident Care and Monitoring
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for several residents, resulting in actual harm for two residents and potential harm for others. One resident with a tooth abscess did not receive prescribed antibiotics in a timely manner, leading to increased pain and infection. The facility did not monitor or assess the resident's oral condition adequately, despite clear signs of infection and repeated complaints of pain. Another resident developed blisters on her breast, which were not properly assessed or treated, leading to deterioration and infection. The facility failed to implement preventative measures and did not document or assess the wound consistently. The resident's care plan was not updated to address the risk factors contributing to the wound, and there was a lack of communication with therapy staff regarding potential causes and solutions. Additional deficiencies included the lack of care planning for a resident undergoing chemotherapy, incomplete wound care documentation for two residents, and inadequate assessment and monitoring of residents sent to the hospital. These failures highlight significant lapses in the facility's ability to provide appropriate and timely care, as well as a lack of effective communication and documentation practices.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, identified as R41, who developed an in-house acquired stage 3 pressure injury on her coccyx. The surveyor observed R41 lying directly on her wound and with her heels in direct contact with the mattress multiple times during the survey. The facility delayed changing R41's bed to a mattress designed to treat stage 3 or higher pressure injuries and did not perform wound care according to physician orders. The facility's policy on pressure injury and skin integrity was not followed, as interventions to mitigate the risk of skin breakdown were not consistently documented or implemented. R41 was admitted to the facility with multiple diagnoses, including morbid obesity, muscle weakness, and heart disease. Her comprehensive care plan included interventions to prevent skin impairment, such as applying barrier cream and ensuring heels were elevated while in bed. However, the treatment administration record showed several instances where these interventions were not completed or documented. Additionally, the facility's use of double briefs, which is not a standard of practice, increased the risk of pressure injuries due to excessive moisture. The facility's documentation and communication regarding R41's pressure injury were inadequate. There were no measurements or descriptions of the wound in the medical record, and the facility failed to notify the primary care physician when the wound opened or changed. The nurse practitioner noted that the wound was a stage 3 pressure injury with 100% slough, which should have been classified as unstageable. Despite the presence of the wound, the facility did not provide an air mattress until several days after the injury was identified, and staff did not consistently ensure that R41's heels were floated or that she was not lying directly on her wound.
Failure in Pain Management for Resident
Penalty
Summary
The facility staff failed to provide appropriate pain management for a resident, identified as R26, who was experiencing severe breakthrough pain. Despite R26's comprehensive care plan indicating a need for both pharmacological and non-pharmacological interventions, the staff did not administer the prescribed PRN pain medication for a period of five hours. This lapse occurred even though the medication was available in the facility's contingency stock. R26, who was cognitively intact and had a history of conditions such as Acute on Chronic Diastolic Heart Failure and Chronic Obstructive Pulmonary Disease, reported a pain level of 9 out of 10, indicating severe discomfort. The deficiency was further compounded by the lack of individualized non-pharmacological interventions in R26's care plan, and there was no documentation of such interventions being performed. Observations and interviews revealed that R26 was visibly in pain, exhibiting signs such as wincing and crying, yet the staff failed to respond promptly to her requests for pain relief. The facility's policy on pain management, which requires regular assessment and documentation of pain and its management, was not adhered to, as evidenced by the delayed response to R26's pain complaints. Interviews with facility staff, including a CNA, LPN, and an agency RN, highlighted communication gaps and procedural failures in accessing and administering the contingency stock medication. The Director of Nursing confirmed that the facility had the necessary medication in stock and that licensed nurses were expected to access it when needed. However, the staff's failure to do so resulted in R26 enduring severe pain unnecessarily, reflecting a significant deficiency in the facility's pain management practices.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies observed during the survey. In one instance, a cognitively intact resident was found to have moldy food in her room, including grapes with visible mold and other perishable items stored at room temperature. The resident admitted to ordering food via Door Dash and storing it improperly. Housekeeping staff had previously noticed moldy food in the resident's room and reported the issue to nursing staff, but the Director of Nursing (DON) was unaware of these reports. Additionally, there was uncertainty about whether Door Dash deliveries were being taken directly to residents' rooms or left at the front desk. Further deficiencies were noted in the facility's kitchen and nourishment room, where several food items were found without proper labeling, including opened bags of baking powder, cake mix, gravy mix, and dry macaroni, as well as an opened gallon of milk and a tube of Braunschweiger without open dates. The Dietary Manager was unsure of when these items were opened and agreed to discard them. Additionally, an ice scoop was found inside the ice machine, posing a risk of cross-contamination, which the Dietary Manager acknowledged should not occur.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, which has the potential to affect all 75 residents. On the morning of October 21, 2024, surveyors observed the main dumpster outside the facility with its lid open. Surrounding the dumpster were various items improperly discarded on the ground, including surgical masks, sealed condiment packets, pre-made condiment containers with lids, numerous used disposable gloves, plastic straws and plasticware, paper towels, and scattered pieces of cardboard. During an interview conducted shortly after the observation, the Dietary Manager (DM Y) acknowledged the situation, stating that the facility attempts to maintain cleanliness in the area whenever garbage is taken out. The manager also indicated that the area should be cleaned up and assured that it would be addressed immediately.
Failure to Conduct Timely and Thorough Staff Background Checks
Penalty
Summary
The facility failed to ensure that staff background checks were completed thoroughly and timely for three out of eight staff members reviewed. Specifically, the background information disclosure (BID) checks for a Medication Technician and two Certified Nursing Assistants (CNAs) were not conducted as required. The Medication Technician's BID had not been updated since the initial check in December 2019, and the CNA's BID had not been updated since November 2019, lacking the necessary Wisconsin results. Additionally, the BID for another CNA was incomplete, with no questions answered on the document. The facility's policies and procedures require that background checks, including re-checks, be conducted every four years and include specific documentation such as a Department of Justice response letter and governmental findings report. However, these requirements were not met for the staff members in question. Interviews with the Human Resources representative and the Nursing Home Administrator confirmed that background checks should be completed every four years and include all necessary documentation, but this was not adhered to in these cases.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication was free from unnecessary medication. The resident, identified as R23, was administered psychotropic and antipsychotic medications without an appropriate diagnosis for the antipsychotic medication. The facility's policy on Psychotropic Medication Management requires that residents should not receive unnecessary medications unless non-pharmacological interventions have failed. However, R23 was prescribed quetiapine for dementia with behaviors, which was acknowledged by the LPN and DON as an inappropriate diagnosis for such medication. Additionally, the facility did not obtain proper informed consent before administering these medications. Verbal consent was obtained from the resident's Activated Power of Attorney for Health Care (APOA-HC) for medications including duloxetine, quetiapine, and hydroxyzine, but no follow-up signatures were obtained. The facility's policy mandates that informed consent, including the explanation of risks and benefits, should be documented and signed. The absence of signatures on the verbal consents was confirmed by both the LPN and DON during interviews. The surveyor's interviews with facility staff revealed that the facility did not adhere to its own policy or regulatory guidance regarding the administration of psychotropic medications. The Nursing Home Administrator acknowledged that the facility's policy did not specify a time frame for obtaining signatures on verbal consents, but agreed that it should be done within two weeks. The lack of appropriate diagnosis and failure to obtain signed informed consent before medication administration were the primary deficiencies identified in this report.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility was found to have a medication error rate of 7.69%, exceeding the acceptable threshold of 5%. This was identified during a medication pass task involving 12 residents, where 2 errors were observed out of 26 opportunities. Specifically, a resident, referred to as R477, was affected by these errors. The errors included the administration of an incorrect dose of calcium carbonate and the omission of Pyridoxine HCl. The Licensed Practical Nurse (LPN) responsible for the medication pass administered a 500 mg tablet of calcium carbonate instead of the prescribed 600 mg, and failed to administer the Pyridoxine HCl due to its unavailability in the contingency stock. During interviews, the LPN acknowledged the errors, attributing the incorrect calcium carbonate dosage to a likely transcription error and the omission of Pyridoxine HCl to its unavailability. The Director of Nursing (DON) confirmed that medications should be administered according to physician orders and acknowledged the transcription error as well. The facility's policy on administering medications emphasizes the importance of following physician orders and administering medications safely and timely, which was not adhered to in this instance.
Failure to Implement Resident's Walking Program
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and assistance to maintain or improve mobility. The resident, who is cognitively intact and has diagnoses including Type 2 diabetes, atherosclerotic heart disease, respiratory failure, chronic pain syndrome, and morbid obesity, was not walked in accordance with his care plan. The care plan required CNAs to assist the resident to ambulate once during each AM and PM shift using a two-wheeled walker, gait belt, and wheelchair to follow. However, facility documentation showed that the resident was not walked on multiple occasions, and no refusals were documented. Interviews with facility staff revealed inconsistencies in the implementation of the resident's walking program. The resident expressed that he was not walked frequently and was unsure if it was his responsibility to ask for assistance. A CNA mentioned it had been weeks since she saw the resident walk, and a Medication Technician stated that the resident often refused to walk but was not always asked. The LPN was unaware of any refusals being reported, and the DON acknowledged that refusals should be documented and reported to a nurse, but it was unclear if the walking plan was being followed.
Infection Control Lapse in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) and the condition of a resident's room. The CNA was observed wearing the same pair of gloves while assisting a resident and then handling clean linens without changing gloves or performing hand hygiene. This action was contrary to the facility's hand hygiene policy, which requires staff to remove gloves and wash hands after resident contact and before handling clean items. Additionally, the resident's room was found to have a strong odor of urine, with soiled linens improperly stored on the floor, which the Licensed Practical Nurse (LPN) confirmed should not have occurred. The resident involved expressed concerns about the cleanliness of her room, which was corroborated by the surveyor and LPN who observed the unsanitary conditions. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged that the CNA should have removed gloves and washed hands after assisting the resident and before handling clean linens. They also confirmed that dirty linens should not be stored on the floor, indicating a lapse in adherence to infection control protocols.
Failure to Implement Effective Emergency Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective emergency training program for all facility and contracted staff. This deficiency was evident as eight facility staff and one contracted staff had not received training on electric power outages and emergency outlets. Additionally, staff were not trained on emergency procedures for severe thunderstorms or tornado warnings. This lack of training was highlighted during a severe weather event when the facility lost electrical power, and the emergency generator was activated. Staff were observed to be unprepared and struggled to manage the situation effectively, as evidenced by their inability to identify which outlets were powered by the generator and their general confusion during the emergency. Interviews with various staff members, including CNAs, RNs, and the Maintenance Director, revealed a consistent lack of knowledge and training regarding emergency procedures. Staff members reported that they had not participated in any drills or received specific training on handling power outages or severe weather events. Some staff were unaware of the existence of emergency outlets, while others did not know which outlets were connected to the generator. This lack of preparedness led to difficulties in providing necessary care to residents, such as ensuring the operation of medical equipment like CPAP machines and oxygen concentrators. Residents also reported experiencing the effects of the staff's unpreparedness. Several residents mentioned that the staff appeared rattled and disorganized during the power outage and tornado warning. Some residents had to wait for staff to locate working outlets for their medical devices, and others noted that the facility's response to the emergency was chaotic. The facility's policies on disaster training and emergency procedures were not effectively implemented, resulting in a failure to ensure the safety and well-being of residents during the emergency event.
Failure to Ensure Proper Enteral Feeding Procedures
Penalty
Summary
The facility did not ensure that a resident who is fed by enteral means received the appropriate treatment and services. The resident, who has diagnoses including dysphagia, aphasia, and intellectual disability, had two different enteral feeding orders that were both being signed out as administered. The resident's enteral feeding bottle was observed without a name, date, or time it was hung for use. The facility policy requires that the enteral nutrition label be checked against the order before administration and that the date and time the formula was hung be documented on the label. However, these steps were not followed, leading to confusion and potential risk for the resident's care. During the survey, it was observed that the resident's tube feeding bottle did not have the required labeling, and the pump was set to 90 ml/hr. The RN interviewed was unable to confirm when the bottle was hung based on the label, and the DON acknowledged that there should only be one tube feeding order and that the bottle should have been labeled with the date and time. The DON also noted that the dietitian had ordered the 90 ml/hr rate in March, but the discrepancy between the two orders had not been clarified, resulting in the resident potentially receiving incorrect feeding amounts.
Failure to Obtain and Transcribe CPAP Orders Upon Admission
Penalty
Summary
The facility failed to ensure that Continuous Positive Airway Pressure (CPAP) orders were obtained and transcribed upon admission for two residents, R5 and R8, who required CPAP therapy for obstructive sleep apnea (OSA). R5 was admitted on 4/18/22 with hospital discharge orders to continue CPAP, but the order was not transcribed into her medical record until 5/24/24. Despite having a care plan indicating the need for CPAP at bedtime, the order was missing from her Medication Administration Record (MAR) until over two years later. R5 confirmed during an interview that she had been using her CPAP nightly for several years and was able to use it during emergency power situations. The Director of Nursing (DON) acknowledged that CPAP orders should have been present from admission and signed off each shift. Similarly, R8 was admitted with a diagnosis of obstructive sleep apnea but did not have CPAP orders obtained or entered upon admission. R8's care plan indicated the need for CPAP, but the orders were not documented until 5/24/24, 43 days after admission. During a power outage, R8 was sent to the emergency room due to the inability to use the CPAP effectively, and upon return, was placed on supplemental oxygen. The DON confirmed that CPAP orders should have been obtained upon admission and that any progress notes indicating oxygen orders should have been transcribed immediately. The failure to obtain and transcribe CPAP orders in a timely manner for both residents highlights a significant lapse in the facility's adherence to professional standards of practice and care planning.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and other officials, including the State Survey Agency. The incident involved a resident with moderate cognitive impairment who was verbally abused by a CNA. The abuse was reported by another CNA who overheard the incident and wrote a statement, but the facility failed to report the incident to the state as required by their policy. The resident involved had a history of hemiplegia, hemiparesis, and cognitive communication deficit following cerebrovascular disease. Despite the facility's policy requiring immediate investigation and reporting of such incidents, the Director of Nursing and the Nursing Home Administrator were unaware of the incident and did not report it to the necessary authorities. This failure to report and investigate the abuse allegation in a timely manner constitutes a deficiency in the facility's compliance with state regulations and their own policies.
Failure to Investigate and Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an accusation of verbal abuse involving a resident with moderate cognitive impairment. The incident occurred when a CNA was overheard using inappropriate language towards the resident. Despite the incident being reported by another CNA, the facility did not conduct a proper investigation or report the allegation to the state agency as required by their policy. The Director of Nursing was unaware of the incident, and the Nursing Home Administrator acknowledged that such incidents should be reported and investigated. The resident involved has a history of hemiplegia, hemiparesis, and cognitive communication deficit following cerebrovascular disease. The resident's Quarterly Minimum Data Set assessment indicated moderate cognitive impairment. The failure to investigate and report the verbal abuse allegation is a clear violation of the facility's policy on abuse, neglect, and exploitation, which mandates immediate investigation and reporting of such incidents to the appropriate authorities.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that three residents received the necessary services to maintain good nutrition, grooming, personal, and oral hygiene. Specifically, residents R3, R10, and R5 did not receive showers as scheduled. R3, who is cognitively intact and requires substantial assistance with bathing, reported not receiving showers due to staff shortages and incorrect documentation of refusals. R3's records showed multiple missed showers and bed baths over a month-long period. R10, also cognitively intact and requiring substantial assistance, similarly reported not receiving scheduled showers. R10's documentation indicated numerous missed showers and bed baths over several weeks. R10 expressed feeling unclean and gross due to the lack of proper hygiene care. Despite asking staff about his shower schedule, R10 did not receive a clear response. R5, who is dependent on staff for bathing, reported not receiving any showers since admission, except for one instance where he declined due to a family visit. R5 requested to see the shower chair before using it but never received it. The Director of Nursing confirmed that missed showers were not documented properly and that scheduled showers should have been completed and recorded. The facility's failure to provide scheduled showers and accurately document refusals led to the deficiency.
Failure to Provide Adequate Care and Monitoring
Penalty
Summary
The facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three of ten residents reviewed for quality of care. Resident 1 (R1) had a history of aspiration pneumonia and refused to comply with thickened liquid recommendations. The facility failed to care plan his refusals or assess R1 more frequently due to his increased risk of aspiration pneumonia. Despite staff observations of R1 drinking thin liquids, there was no investigation or education provided to staff on therapeutic diets and reporting dietary concerns. R1 was eventually sent to the ER with pneumonia and did not return to the facility. Resident 5 (R5) had diagnoses including morbid obesity and diabetes mellitus type two. The facility staff were not monitoring R5's bowel movements adequately. R5 experienced episodes of going several days without a bowel movement, and there was a lack of awareness among the staff regarding his bowel movement patterns. R5 also reported dietary needs that were not being met, contributing to his constipation. The facility's Director of Nursing (DON) was unaware of the specific episodes of constipation and did not have a clear protocol for monitoring bowel movements. Resident 3 (R3) did not receive wound care two times in one week for two wounds. The facility's Treatment Administration Record (TAR) showed blanks for the dates when wound care was not completed. The Treatment Nurse (TN) confirmed that if the TAR is blank, it indicates that the treatment was not done. The DON acknowledged that blanks on the TAR indicate that treatments were not documented and would need to investigate further. The facility failed to ensure that wound care was completed and documented as ordered, leading to lapses in R3's wound care treatment.
Failure to Monitor Blood Glucose Levels
Penalty
Summary
The facility did not ensure that the services provided by nursing personnel met the professional standards of quality for one resident. The resident was admitted with orders for Point of Care glucose testing (POCT) four times daily before meals and at bedtime. However, the facility failed to monitor the resident's blood glucose levels during their stay. This deficiency was identified through interviews, record reviews, and a review of professional standards of practice. The facility's policy on diabetes management required blood glucose monitoring upon admission and throughout the resident's stay, but this was not followed for the resident in question. The resident had a diagnosis of Type 2 Diabetes Mellitus, epilepsy, and nausea with vomiting. The hospital discharge summary included orders for POCT glucose monitoring and specific instructions to notify the Primary Care Physician if blood glucose levels were outside the specified range. Despite these orders, the resident's Medication Administration Record (MAR) for March and April did not include the POCT glucose monitoring order. The Director of Nursing confirmed that the order was not on the MAR and that the glucose levels were not being monitored as required. The failure to clarify and implement the discharge orders led to the deficiency in care for the resident.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility did not ensure the provision of pharmaceutical services to meet the needs of a resident, resulting in the resident not receiving her prescribed medications on a specific date. The resident, who has diagnoses including Type 2 Diabetes Mellitus, epilepsy, and essential hypertension, did not receive her ordered doses of amlodipine, ezetimibe, and carbamazepine. The facility's policy requires medications to be administered in a safe and timely manner, and any deviations must be documented in the Medication Administration Record (MAR) and nurse notes, which was not done in this case. The Medication Administration Record (MAR) for the resident showed that the medications were not administered, and the sign-out boxes were marked with a code indicating 'Other, See Nurse Notes.' However, there were no corresponding notes explaining why the medications were not given. Interviews with the nursing staff revealed that there is a process in place to obtain medications that are not available in the medication cart, including checking the Omnicell, calling the pharmacy, and contacting the Nurse Practitioner (NP) for alternative orders. Despite these procedures, the medications were still not administered as ordered. The Director of Nursing (DON) confirmed that it is the facility's expectation that all ordered medications are to be administered. The DON also outlined the steps to be taken if a medication is not available, which include checking the Omnicell, contacting the pharmacy, and consulting the NP. The failure to administer the medications as ordered and the lack of documentation in the nurse notes indicate a lapse in following the facility's policies and procedures for medication administration.
Supervision and Response Deficiencies in Elopement Incident
Penalty
Summary
The report details a significant deficiency in a nursing home's supervision and response to an elopement incident involving a resident identified as R5. R5, who had a complex medical history including diagnoses of cerebral infarction, dementia, muscle weakness, and mobility issues, was assessed to be at risk for elopement due to impaired safety awareness. Despite wearing a WanderGuard device and being identified as an elopement risk, R5 managed to elope from the facility on two occasions. The first elopement occurred on 12/18/23, and the second, more serious incident took place on 02/25/24, leading to the finding of Immediate Jeopardy. The facility's failure to provide adequate supervision and respond effectively to alarms during R5's elopement on 02/25/24 resulted in a situation of Immediate Jeopardy. Staff members, including a Registered Nurse and Certified Nurse Aide, did not respond promptly to the alarm triggered by R5's exit through a front door, with the alarm being reset without verifying R5's whereabouts. Subsequently, a delayed search was initiated, and law enforcement was not notified promptly, leading to R5 being found at a gas station approximately 1.5 miles away from the facility. The deficiency in supervision and response protocols, as highlighted in the report, directly contributed to the elopement incident and the subsequent Immediate Jeopardy finding. Despite R5's known elopement risk, documented in assessments and care plans, the facility's policies and procedures regarding elopement and wandering lacked specific guidance on timely notification of law enforcement and ensuring door alarms remain active until the resident is located. The report also highlighted discrepancies in staff actions and responses during the elopement incident, including delays in contacting law enforcement and inconsistencies in searching for R5 within the facility. These deficiencies in policy implementation and staff actions directly contributed to the failure to prevent R5's elopement and the subsequent Immediate Jeopardy situation.
Failure to Prevent Staff-to-Resident Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident abuse when an LPN allegedly physically grabbed a resident's arm and removed a dab/vape pen from the resident's hand. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a care plan in place to monitor for unsafe items and hold them for the resident's family to pick up. The incident occurred when the LPN, accompanied by another LPN, entered the resident's room to retrieve the dab/vape pen. The resident reported feeling violated and called the police to report the incident. Multiple staff members, including the Social Services Director and a CNA, corroborated the resident's account that the LPN had physically taken the pen from the resident's hand against their will. The Director of Nursing (DON) was initially unaware of the physical nature of the incident and did not report it to the State Agency or investigate it until later informed. The DON then suspended the LPN and initiated an investigation. The facility's policy on abuse, neglect, and exploitation, which was revised recently, mandates protections for residents' health, welfare, and rights, and prohibits such actions. Despite this policy, the incident was not reported immediately by the involved staff, and the grievance form was only filled out after the resident had already contacted the police.
Failure to Timely Report Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse to the State Agency (SA) within the required timeframe. The incident involved a resident with multiple sclerosis, bipolar disorder, and anxiety disorder, who was cognitively intact as indicated by a BIMS score of 15 out of 15. The resident alleged that an LPN physically grabbed his arm and removed a dab/vape pen from his hand. The resident did not initially report the incident to the facility but called the police instead. The facility's policy mandates that such allegations be reported immediately, but not later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury. However, the incident was not reported to the SA until several days later, after the Director of Nursing (DON) became fully aware of the resident's allegations. Interviews with various staff members, including the LPN involved, the Social Services Director (SSD), and a Certified Nurse Aide (CNA), confirmed the resident's account of the incident. The LPN admitted to taking the dab/vape pen from the resident's hand but claimed he did not use excessive force. The SSD and CNA corroborated the resident's story, stating that the LPN physically took the pen from the resident's closed fist. Despite being informed of the incident on the day it occurred, the DON did not report it to the SA until several days later, after realizing the resident had accused the LPN of physical abuse. This delay in reporting constitutes a failure to comply with the facility's abuse prevention and reporting policies.
Failure to Investigate Allegation of Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident and an LPN. The incident involved the LPN allegedly grabbing the resident's arm and forcibly removing a dab/vape pen from the resident's hand. The resident, who has multiple sclerosis, bipolar disorder, and anxiety disorder, reported the incident to the police but did not initially inform the facility. The facility's grievance form documented the resident's complaint about the removal of the dab/vape pen, but the initial response did not include a thorough investigation into the physical abuse allegation. Interviews with the resident, the LPN involved, and other staff members revealed conflicting accounts of the incident. The LPN claimed that the resident voluntarily allowed the pen to be taken, while other staff members reported that the LPN aggressively grabbed the pen from the resident's hand. The Director of Nursing (DON) was initially unaware of the physical abuse allegation and did not investigate the incident until several days later. The facility's failure to promptly and thoroughly investigate the incident resulted in a deficiency in protecting the resident from potential abuse.
Failure to Provide CPAP Machine as Ordered
Penalty
Summary
The facility failed to ensure that a resident (R8) was using a continuous positive airway pressure (CPAP) machine as ordered by the resident's physician. The resident was admitted on an unspecified date and had a physician's order to use a CPAP machine. The resident's admission Minimum Data Set (MDS) indicated that the resident was cognitively intact with a score of 15 out of 15. An observation of the resident's room revealed that there was no CPAP machine near the bedside. The resident confirmed in an interview that she did not have a CPAP machine in her room to use at night. An LPN stated that the resident did not have a CPAP machine and that the physician was not notified of the inability to follow the physician's orders. The Director of Nursing (DON) confirmed that the resident did not have a CPAP machine available and that the physician was not notified of the facility's inability to follow the physician's orders.
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What surveyors actually found near you
We read the 345 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
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Nursing homes near Middleton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hebron Oaks | 3.9 mi | ★★★★★ | 3 | 0 |
| Oak Park Place Of Nakoma | 4 mi | ★★★★★ | 19 | 0 |
| Capitol Lakes Health Center | 5.4 mi | ★★★★★ | 11 | 1 |
| Complete Care At Maple Grove Llc | 5.4 mi | ★★★★★ | 0 | 0 |
| Waunakee Valley Senior Living | 6.7 mi | ★★★★★ | 15 | 0 |
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