Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montello Care Center during CMS and state inspections, most recent first.
Failure to Supervise Resident With Suicidal Ideation: A resident with depression and moderate cognitive impairment expressed suicidal thoughts and was placed on 15-minute checks, but the checks were not completed for the full ordered period. The resident later pulled a call light from the wall, threatened to wrap the cord around their neck, and was then found with the cord wrapped around their neck while screaming that they wanted to kill themself. Staff interviews confirmed the resident was not on increased supervision when the threats and self-harm behavior occurred.
Failure to thoroughly investigate resident altercations and an alleged abuse incident. The facility reviewed several resident-to-resident incidents and one report of rough peri-care by a CNA, but did not interview all possible witnesses or other residents with knowledge of the events. In one case, a resident was placed on 1:1 supervision, but there was no documentation that the supervision was provided.
Failure to Provide Required Transfer and Discharge Documentation: A resident with depression, chronic pain, and moderate cognitive impairment made suicidal statements and was found with a call light cord wrapped around the neck. After EMS and a crisis team were involved, the NHA told the POAHC the resident could not return because the facility could not meet the resident’s mental health needs, but the POAHC did not receive a written transfer notice and the chart lacked a bed hold notice, discharge summary, and recapitulation of stay.
Incomplete Food Safety and Sanitation Monitoring: Staff did not consistently document food holding and cooking temps, sanitizer solution conditions, cooler/freezer temps, or dish machine chlorine and temp logs. The DM and a cook confirmed missing entries and that solution temp was not checked before sanitizer testing. Survey review showed repeated omissions across kitchen, unit refrigerator, and dishwashing records, along with sanitizer readings that were not consistently documented as required.
Failure to provide transfer, bed-hold, and Ombudsman notifications: A resident with intact cognition was transferred to the hospital multiple times, but the facility did not provide written transfer notices or bed-hold information for all hospitalizations. Staff also confirmed that transfer/discharge notices were not being sent to the State LTC Ombudsman for several months, and the SW stated they were unaware of that responsibility.
A kitchen oven door would not stay closed and was being held shut with a bungee cord. When the cord was removed, the door fell open without resistance. A CK reported being burned when the door fell open, and the DM confirmed the door had been broken for years and that residents had entered the kitchen area during dining hours.
A resident with significant medical needs was found between the bed and the wall with visible injuries. Staff provided inconsistent accounts regarding the presence and extent of these injuries, with an LPN reporting no injuries and a CNA observing swelling and blood. The incident was not documented in the medical record, and facility administration did not investigate the discrepancy between staff statements.
Call lights were not within reach for two residents during survey observations. One resident with dementia, stroke, psychosis, and other diagnoses was seen in a wheelchair with the call light on the bed and later on the floor, both times out of reach. Another resident with dementia, epilepsy, respiratory failure, and cognitive communication deficit was seen in a Broda chair with the call light on the bed and later attached to a pillow behind the chair, also out of reach. A CNA and the ADON verified the call light should have been within reach.
Failure to Issue NOMNC Forms: Two residents did not receive a CMS-10123 NOMNC at least two calendar days before their Medicare Part A coverage ended, and there was no evidence that either resident or representative was informed of appeal rights. The NHA verified the notices were not issued, and the SW confirmed the forms were not provided.
A resident with neurocognitive disorder with Lewy bodies, insomnia, anxiety, psychosis, and conduct disorder received trazodone at bedtime for insomnia, but the record lacked a sleep assessment and an insomnia care plan. The ADON verified that the resident was receiving the psychotropic medication without documented monitoring of its effectiveness.
The facility failed to follow its abuse prevention policy for one CNA-R hired through a staffing agency. Record review showed the CNA lived in Louisiana within 3 years of hire, but the required out-of-state background check was not available when the surveyor requested it. The NHA stated the facility relied on the staffing agency to complete the background check and that the document had not been received.
PASRR screening was not completed correctly for two residents. One resident was admitted with epilepsy, but the PASRR Level I Screen did not include that diagnosis and no Level II referral was made. Another resident later developed psychotropic medication needs for psychosis, anxiety, depression, insomnia, and conduct disorder, but the facility did not redo the PASRR Level I Screen or submit a Level II referral.
Inadequate nail care for two residents was identified after surveyors observed long, jagged fingernails with dirt and chipped polish. One resident had Alzheimer’s disease and cognitive deficits, and the other had dementia and multiple psychiatric and neurologic diagnoses; both care plans called for staff assistance with ADLs. The DON observed the residents but did not identify the nail care concerns, and an ADON stated nails should be short, clean, and not jagged, with CNAs trimming and cleaning nails on shower days.
A resident with stroke, foot drop, dementia, and muscle wasting had a care plan for a functional restorative program with PROM to the upper and lower extremities 1 to 2 times daily, but surveyors found the program was not consistently provided. Staff gave conflicting accounts about whether PROM was done, the restorative materials were missing from the closet, and the NHA confirmed there was not sufficient charting and that documentation for PROM was scarce and lacking.
Medication administration was not carried out as ordered for one resident with severe cognitive impairment, including a delayed buprenorphine patch and missed guaifenesin ER dose, because staff could not locate the medications in the cart and the patch was not given when received. For another resident with intact cognition but an assessment showing the resident was not appropriate to self-administer, staff still left medications at the bedside for the resident to take independently, despite no self-administration order or care plan.
Failure to monitor adverse reactions to a high-risk antibiotic was identified for a resident receiving cefdinir for prophylactic measures due to a history of UTIs. The resident had diagnoses including urinary retention, indwelling catheter-related infection/inflammation, and sepsis, and the record did not show monitoring for adverse effects despite the facility policy requiring monitoring for high-risk meds such as antibiotics. The RNC confirmed the monitoring had not been implemented.
Failure to assess two residents for PFA feeding assistance: Two residents with severe cognitive impairment and dysphagia were assisted by trained PFAs even though their records did not show an IDT assessment approving them for the PFA program. Both residents had SLP findings documenting swallowing problems and specific feeding recommendations, yet the care plans did not identify them as appropriate for PFA support. One PFA reported assisting with meals and cueing, while the facility stated PFAs should not physically assist or cue residents with dysphagia.
A resident with a Foley catheter was not placed on EBP, and staff provided high-contact care without consistent PPE use or hand hygiene. An agency CNA emptied the catheter bag and later performed catheter/peri-care and brief care without always wearing a gown or cleaning hands between glove removal and donning clean gloves. The DON acknowledged the resident should have been on EBP and that no EBP sign was posted near the door.
A resident with dementia became agitated and attempted to leave the facility after resisting bedtime care. Multiple staff members physically blocked exits and restrained the resident, escalating the situation and resulting in injuries to staff. These actions were inconsistent with the resident's care plan and facility policies, which required less restrictive interventions and prohibited physical restraint and blocking of exits.
A resident with Alzheimer's disease became agitated and attempted to leave the facility, leading staff to physically restrain the individual and call law enforcement. The resident later alleged being attacked by multiple people, and police observed staff holding the resident in a chair. Despite facility policy, the incident was not reported to the State Agency, and the NHA did not conduct staff interviews or review all relevant documentation.
A resident with Alzheimer's disease became agitated and attempted to leave the facility, leading staff to physically restrain the resident and block exits. The facility did not conduct a thorough investigation, as several involved staff were not interviewed and external reports from police and county crisis services were not obtained or reviewed, resulting in an incomplete investigation of the abuse allegation.
Two residents with severe cognitive impairment were involved in an incident where one struck the other in the face, witnessed by a Med Tech. Although facility policy required reporting such events to law enforcement, the administrator did not notify authorities, citing the residents' inability to recall the event and a belief that the incident was not malicious. The facility's policy also lacked clear guidance on what crimes should be reported and did not reflect consultation with law enforcement.
Surveyors observed that the facility's front area was unkempt, with long weeds, an open dumpster lacking full fencing, exposed wires from a missing doorbell, and various items such as uncovered garbage cans and a laundry bin. The front doors, which were required to be locked during night hours, were found unlocked. These deficiencies in maintaining a safe and sanitary environment had the potential to affect multiple residents.
A resident with complex medical needs did not receive necessary care to prevent pressure injuries when staff failed to properly assess and address a malfunctioning wound vac dressing. Despite reports from CNAs that the dressing was not suctioning and was bunched up, the DON did not assess the wound vac, and the resident's wound condition deteriorated, with subsequent signs of infection and the need for alternative wound care. Facility policies for negative pressure wound therapy and pressure injury prevention were not followed, and staff education on wound vac management was insufficient.
A resident with recent cervical spine surgery, Parkinson's disease, and mobility limitations fell out of bed after a CNA left the room, was unable to reach the call light, and called 911 for help. The facility did not complete a thorough investigation or root cause analysis of the fall, and required documentation and interviews were missing from the event report and medical record.
A resident with osteomyelitis requiring continuous IV antibiotics missed a scheduled dose when the DON failed to change the medication cartridge as ordered. Staff and the resident confirmed the missed dose, and an unused cartridge was discarded, indicating the medication was not administered as documented.
A deficiency was identified when the DON assessed a resident with severe cognitive impairment and respiratory issues but failed to document the assessment in the medical record, despite facility policy requiring complete and accurate documentation of all observations and changes in condition. The assessment was only communicated verbally to the RN, resulting in incomplete records for the resident.
A registered nurse did not follow infection control protocols during wound care for a resident with complex medical needs, including not performing hand hygiene between glove changes and using soiled scissors to cut a clean dressing. Facility policies required hand hygiene after glove removal and the use of sanitized equipment, but these were not followed during the observed wound care procedure.
Two residents with dementia and activated POAHCs were involved in a series of incidents where one resident, with a known history of sexually inappropriate and aggressive behavior, was not consistently monitored or managed according to policy. Despite multiple documented episodes of inappropriate comments, aggression, and boundary violations, care plans were not updated and incident reports were lacking. This failure led to an incident where a cognitively impaired resident was sexually abused by another resident, with staff and administration interviews confirming gaps in documentation and follow-up.
Two residents were involved in incidents of sexually inappropriate, verbally, and physically aggressive behavior, as well as a verbal altercation. Staff documented these events in progress notes but did not report the allegations of abuse to the State Agency or conduct required investigations, as confirmed by interviews with an LPN, the DON, and the NHA. This failure to follow abuse reporting policies resulted in a deficiency.
Two residents were involved in multiple incidents of sexually inappropriate, verbally, and physically aggressive behavior, as well as a verbal altercation over personal property. Despite documentation of these events, facility leadership could not provide evidence of investigations or detailed reviews as required by policy, and there was no documentation of actions taken in response to the incidents.
Three residents with severe cognitive impairment and high fall risk experienced multiple falls, but their care plans were not consistently or promptly updated to reflect new or revised interventions. In several cases, interventions were either delayed in being added to the care plan or not documented at all, despite staff reporting that changes had been made. Staff interviews confirmed that care plan updates were not always completed as required.
A resident with severe cognitive impairment engaged in multiple altercations with other residents due to inadequate supervision. Despite being placed on 1:1 supervision, the resident was not consistently monitored, leading to physical altercations. Staff were not properly trained or informed about the use of monitoring devices, and there was no specific assignment for 1:1 supervision, resulting in lapses in care.
Two residents with cognitive impairments were involved in a physical altercation, which was not reported to the State Agency as required by the facility's policy. One resident required 1:1 supervision, which was not provided at the time of the incident. The Nursing Home Administrator confirmed the incident was not reported because there were no physical injuries.
The facility failed to maintain sanitary food storage and preparation practices, affecting all residents. Cooling logs for leftover foods were incomplete, and cleanliness issues were noted in the resident snack refrigerator. Food holding temperatures were not monitored, and items lacked proper labeling, with some beyond discard dates.
The facility failed to maintain an effective infection prevention and control program, lacking monthly and quarterly infection surveillance reports. Additionally, Enhanced Barrier Precautions (EBP) were not implemented for residents with a history of multi-drug resistant organisms (MDROs), despite their medical conditions requiring such precautions. The Director of Nursing confirmed these deficiencies during the survey.
The facility failed to maintain a clean and homelike environment due to a persistent urine odor noted by surveyors and confirmed by staff, a resident, and a family member. The odor was strongest in the 100 wing and was attributed to factors such as lack of air fresheners, caulk around toilets, and unsealed trash cans.
The facility failed to investigate potential abuse incidents involving five residents, including injuries of unknown origin and resident-to-resident altercations. In one case, a resident with moderate cognitive impairment had an unexplained bruise, and in two separate altercations, residents with severe cognitive impairments were involved in physical contact. The investigations were incomplete or not conducted, indicating deficiencies in the facility's abuse prevention program.
The facility failed to provide adequate assistance with ADLs for five residents, including meal assistance for a resident with dementia and consistent weekly showers for four residents. Observations revealed that CNAs were unable to provide proper feeding assistance due to attending multiple residents simultaneously. Additionally, residents reported and documentation confirmed missed showers due to short staffing. The DON acknowledged the lack of adherence to care plans and resident preferences.
The facility did not adhere to its abuse policy by failing to complete timely background checks for four out of eight sampled staff. The policy requires checks to prevent employing individuals with histories of abuse or related issues. However, reports for a CNA and a Dietary Aide were not obtained, and a Physical Therapist's reports were delayed. Additionally, a CNA's background check was outdated. The Regional Director acknowledged the issue, citing the absence of an HR Director as a contributing factor.
A resident's grievance about unresponsive call lights was not promptly addressed due to the facility's phone system issues, which prevented family members from reaching staff. The resident, with intact cognition, had to rely on a family member to call the facility, but calls went unanswered, and there was no voicemail option. The facility's grievance policy was not followed, and the issue was not documented in the grievance file.
The facility failed to report incidents of potential abuse and resident altercations to the appropriate authorities. A resident with moderate cognitive impairment was found with an unexplained bruise, and a physical altercation occurred between two residents, one with severe cognitive impairment. The facility did not notify the State Agency or the family of the affected resident, indicating a lapse in following the abuse prevention policy.
A resident was transferred to the hospital without receiving a written notification of transfer, including the reason, location, appeal rights, and Ombudsman contact information. The resident's medical record lacked documentation of the transfer details, and interviews with facility staff confirmed the absence of the required notice.
A facility failed to provide a written bed hold notice to a resident transferred to the hospital, as required by their policy. The resident, with intact cognition and multiple diagnoses, did not receive the notice detailing the bed-hold policy, reserve bed payment, and right to return. This deficiency was confirmed by the Regional Director of Operations.
A facility failed to complete a PASRR Level II Screen for a resident with a history of mental illness, despite being prescribed psychotropic medications and remaining in the facility beyond the 30-day exemption period. The oversight was confirmed through staff interviews and a review of the resident's medical record, which lacked documentation of a necessary county exemption.
A facility failed to create a comprehensive care plan for a resident identified as a potential unsafe smoker. The resident, with severely impaired cognition and multiple diagnoses, was assessed to have moderate problems with smoking safety. Despite this, no smoking care plan was documented until requested by a surveyor, indicating a lapse in following the facility's smoking policy.
A resident with an indwelling catheter did not receive appropriate care to prevent UTIs, as staff failed to keep the catheter drainage bag below the bladder level, obstructing urine flow. The facility's policy requires the bag to be positioned lower than the bladder, which was not adhered to during care and dressing changes.
A resident with severe cognitive impairment and multiple health conditions did not receive fluids between meals as required by the facility's policy. Observations and staff interviews confirmed the absence of thickened liquids in the resident's room, and the Director of Nursing acknowledged the expectation for staff to provide fluids, which was not met.
The facility failed to monitor high-risk medications for two residents, leading to deficiencies in their care plans. One resident was not monitored for side effects of insulin and bumetanide, while another was not monitored for bleeding related to apixaban use and was not weighed weekly as ordered. These oversights were confirmed by the DON.
The facility failed to document the rationale for continued PRN use of lorazepam beyond 14 days for three residents, as required by policy. Despite having diagnoses such as dementia and anxiety, the residents' medical records lacked necessary documentation, and interviews with the DON and an LPN confirmed this oversight.
Failure to Supervise Resident With Suicidal Ideation
Penalty
Summary
The facility failed to provide adequate supervision for a resident with depression, chronic pain, neuropathy, type II diabetes, and moderate cognitive impairment who expressed suicidal ideation and threats of self-harm. The resident’s MDS dated 4/6/26 showed a BIMS score of 9 out of 15, and the resident’s POAHC was activated during the admission. The resident had been admitted with a care plan focused on adjustment to the facility, with interventions to check in with the resident, orient the resident to the facility, and accompany the resident as needed. On 4/19/26, the resident stated they were going to kill themself and was placed on close observation and 15-minute checks for 72 hours. Documentation of the 15-minute checks began on 4/19/26 at 2:00 PM and ended on 4/21/26 at 10:00 PM, totaling 56 hours rather than the ordered 72 hours. The resident continued to display confusion, calling out, screaming, and statements such as feeling down and wishing they were dead. A physician note on 4/20/26 described recent behavioral escalation, suicidal ideation after the resident’s spouse left in the evening, and consideration of CBT, which was not pursued. On 4/22/26, the resident’s care plan was updated for behavior symptoms, including accusations of self-harm or negative statements triggered by the spouse leaving, but the resident was not on increased supervision at that time. CNA-C reported that around 10:00 PM on 4/22/26 the resident pulled the call light out of the wall, attempted to hit staff with it, and stated they wanted to kill themself and would wrap the cord around their neck. LPN-H verified the resident was upset, had to have the call light replaced, and was not on 15-minute checks or increased supervision. On the morning of 4/23/26, CNA-D found the resident with the call light cord wrapped twice around their neck while the resident was screaming that they wanted to kill themself. DON-B and NHA-A verified the incident and that the resident was hospitalized afterward.
Failure to Thoroughly Investigate Resident Altercations and Alleged Abuse
Penalty
Summary
The facility did not thoroughly investigate multiple resident-to-resident altercations and one potential allegation of abuse involving 6 residents. The facility’s Abuse, Neglect, and Exploitation policy, revised 1/2026, required an immediate investigation when abuse, neglect, or exploitation was suspected or reported and required interviews of all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the allegation. On 5/4/26, the surveyor reviewed records and facility-reported incidents showing that the required scope of investigation was not completed for several events. On 2/16/26, R3 and R4 were involved in an altercation after R3 self-propelled a wheelchair into R4’s wheelchair in the lobby area. R3 had diagnoses including dementia, mild cognitive impairment, unspecified mood disorder, insomnia, anxiety, and emotional lability, with a BIMS score of 5/15 indicating severe cognitive impairment and an activated POAHC. R4 had diagnoses including dementia, anxiety, major depressive disorder, and unspecified psychosis, with a BIMS score of 2/15 indicating severe cognitive impairment and an activated POAHC. The investigation included interviews with R3 and R4, but did not include interviews with other residents who may have witnessed the incident or experienced a similar occurrence. On 2/24/26, R1 and R2 were involved in an altercation in a lounge while waiting for meals. R1 had diagnoses including anoxic brain damage, depression, and anxiety, with a BIMS score of 5/15 and an activated POAHC. R2 had diagnoses including neurocognitive disorder with Lewy Body, anxiety, unspecified psychosis, and insomnia, with a BIMS score of 00/15 and an activated POAHC. The facility’s investigation included interviews with R1 and R2, but did not include interviews with other residents who may have witnessed the incident or experienced a similar occurrence. The investigation also indicated R2 would be on 1:1 supervision, but the facility did not have documentation that the 1:1 supervision was provided. On 4/22/26, R5 and R3 were involved in an altercation when R3 grabbed R5’s sheet and hit/punched R5 in the knee/leg; R5 had intact cognition and R3 had severe cognitive impairment with an activated POAHC. The facility interviewed R3 and R5, but did not interview other residents who may have witnessed the incident or experienced a similar occurrence. On 2/21/26, R6 reported that a male CNA entered the room, closed the door, and washed R6’s vagina and buttocks roughly and aggressively with a washcloth. R6 had diagnoses including acute chronic respiratory failure with hypoxia, bipolar disorder, and anxiety, with a BIMS score of 11/15 and a guardian. The investigation included an interview with R6, a police investigation, and a negative SANE exam, but did not include resident interviews to determine whether others had similar concerns or staff interviews to determine whether staff witnessed similar events or received similar complaints.
Failure to Provide Required Transfer and Discharge Documentation
Penalty
Summary
The facility did not ensure an appropriate discharge process for a resident with depression, chronic pain, and moderate cognitive impairment, who had an activated POAHC. On 4/23/26, the resident made suicidal statements and was found with a call light cord wrapped around the neck, prompting staff to call EMS and notify the PCP. A crisis team developed a safety plan that included removing cords from the resident’s room and increasing supervision, and EMS, the resident, and the POAHC initially determined the resident did not need hospital transfer. NHA-A later told the POAHC that the facility could not meet the resident’s needs and that the resident could not return because the facility could not meet the resident’s mental health needs. The POAHC did not receive a written transfer notice, and the resident’s record did not contain a bed hold or transfer notice, discharge summary, or recapitulation of stay. The discharge MDS dated 4/23/26 indicated the resident’s return was not anticipated.
Incomplete Food Safety and Sanitation Monitoring
Penalty
Summary
Food was not consistently stored, prepared, and served in a sanitary manner. During an initial kitchen tour, the Dietary Manager stated the facility followed the Wisconsin Food Code as its standard of practice. Survey review of October and November 2025 food holding and cooking temperature logs found missing documentation across all three daily meals, including meals without cooking and holding temperature entries, meals without holding temperatures, and meals without cooking temperatures. The Dietary Manager confirmed the missing entries and stated that cooking and holding logs should be consistently completed. The manager also stated that beverages remained out of the cooler during meal service, which could extend up to two hours, and acknowledged that staff had not been recording holding temperatures for cold items. The facility also did not consistently verify or document sanitizer conditions. At the three-compartment sink, surveyors observed sanitizing buckets and a quat sanitizer testing log that required twice-daily readings of 200 PPM, but the log did not include a place to record the temperature of the sanitizing solution. The Dietary Manager stated the facility used Hydrion QT-40 sanitizer test strips and confirmed the facility did not verify or document the solution temperature before testing. A cook was observed filling the sink with water and sanitizer and testing the solution without checking temperature first, and the cook confirmed that checking the temperature was not part of the facility’s standard procedure. Survey review of the sanitizer test strip logs identified multiple missing entries over the two-month period. Kitchen and dishwashing temperature monitoring was also incomplete. Survey review of the main kitchen cooler, freezer, and unit snack refrigerator logs showed repeated missing temperature entries in October and November. The facility required three daily checks for the main kitchen units and twice-daily checks for the snack refrigerator, but the logs contained numerous omissions. For the dish machine, the facility used a low-temperature chemical dish machine with a data plate specifying minimum wash and rinse temperatures of 120 F and a chlorine rinse concentration of 50 PPM. Survey review of the chlorine test strip log and dishwasher temperature log found incomplete entries and multiple chlorine readings at or above 100 PPM. The Dietary Manager acknowledged the missing dishwasher temperature and chlorine test strip entries and confirmed that all log entries should be consistently completed.
Failure to Provide Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility did not ensure that one resident, R10, received written transfer and bed-hold notices, including information about the right to return to the facility, when the resident was transferred to the hospital on 9/22/25, 10/10/25, and 11/18/25. R10 was admitted to the facility with diagnoses including local infection due to central venous catheter, and the 11/26/25 MDS showed a BIMS score of 15 out of 15, indicating intact cognition and that R10 was responsible for healthcare decisions. The medical record did not include documentation that written transfer notices were provided for any of the hospital transfers, and bed-hold information was not provided for the 9/22/25 and 10/10/25 hospitalizations. The facility also did not notify the Office of the State LTC Ombudsman of resident transfers and discharges for 4 consecutive months. During interview, the Regional Nurse Consultant stated the Social Worker was responsible for issuing transfer/discharge and bed-hold notices, and the Social Worker confirmed that written transfer and bed-hold notices were not provided to R10. The Regional Nurse Consultant also stated that the Ombudsman notification process had not been completed since the Social Worker was hired, and the Social Worker stated they were not aware of the responsibility to notify the State LTC Ombudsman of transfers and discharges and had not done so since starting at the facility.
Broken Kitchen Oven Door Held Shut With Bungee Cord
Penalty
Summary
The facility did not ensure essential equipment was maintained in safe operating condition when the kitchen oven door was not working properly. During a follow-up visit to the kitchen, surveyors observed a black bungee cord tied around the oven door handle and secured to the leg of a side table to keep the door shut. When the cord was removed, the oven door fell open without resistance. The oven was identified as a Vulcan VG260 gas restaurant range with two ovens, and staff stated the door would not stay closed and would slam open if it was not secured. The kitchen staff member stated the oven door had been broken for about 3 years and reported being injured when the door fell open and burned the lower leg. The dietary manager confirmed the door was broken, did not remain closed unless held with a bungee cord, and had been broken for several years. The dietary manager also stated residents had entered the kitchen through the open door during dining hours and that residents could get within a few feet of the kitchen door before staff could assist them. The nursing home administrator acknowledged awareness that the oven door was broken and held shut by a bungee cord and stated the door had been broken since starting in October.
Failure to Investigate Discrepancy in Resident Injury Reports
Penalty
Summary
The facility failed to thoroughly investigate a potential allegation of abuse involving one resident who was found between the wall and the bed with injuries including a swollen right eye, facial swelling, and abrasions on the right shoulder and arm. The resident, who had significant medical conditions such as anoxic brain damage, epilepsy, and hemiplegia, was dependent on staff for care, transfers, and mobility. Staff interviews revealed inconsistent accounts regarding the presence and extent of the resident's injuries. One LPN reported finding the resident without injuries or bleeding and only cleaned sputum from the face, while a CNA described the resident as having a swollen, bloodied face and observed bloody washcloths nearby. The LPN did not document the incident in the medical record, and the discrepancy between staff statements was not investigated further by facility administration. The facility's administration was notified of the incident and initiated an investigation, but failed to address or reconcile the conflicting staff statements regarding the resident's injuries. The Nursing Home Administrator confirmed that there was no follow-up to investigate the discrepancy between the LPN and CNA accounts. As a result, the facility did not ensure a thorough investigation of a potential abuse allegation, as required, and did not document or clarify the circumstances surrounding the resident's injuries.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility did not ensure call lights were within reach for 2 residents, R8 and R12, during observations by the surveyor. The facility policy, Answering the Call Light, revised September 2022, states that call lights should be accessible to residents when in bed, from the toilet, from the shower or bathing facility, and from the floor. R8 was most recently admitted with diagnoses including dementia, affective mood disorder, anxiety, stroke, convulsions, psychosis, and insomnia, and the MDS dated 9/26/25 indicated R8 was rarely/never understood and had a guardian for healthcare decisions. On 12/1/25, R8 was observed in a wheelchair by a window with the call light on the bed and not within reach, and on 12/3/25 R8 was again observed in a wheelchair with the call light on the floor at the foot of the bed and not within reach. R12 was most recently admitted with diagnoses including dementia, epilepsy, respiratory failure, cognitive communication deficit, anxiety, depression, and stroke. R12's MDS dated 10/7/25 showed a BIMS score of 99, indicating the resident could not complete the assessment, and R12 also had a guardian for healthcare decisions. On 12/1/25, R12 was observed in a Broda chair next to the bed with the call light on the bed and not within reach. On 12/3/25, R12 was again observed in a Broda chair with the call light on the bed attached to a pillow behind the chair and not within reach. The surveyor activated R12's call light and verified it worked, and CNA-Q later verified the call light should have been within R12's reach. ADON-M also verified that a resident's call light should always be within reach.
Failure to Issue Medicare Non-Coverage Notices
Penalty
Summary
The facility did not ensure that residents received a Notice of Medicare Non-Coverage (NOMNC) form at least two calendar days before their Medicare Part A services ended. The report states that the facility’s policy required timely Medicare coverage notices, including issuance of CMS-10123 when Medicare-covered services were ending, and that the notice should be provided at least two days before the end of a Medicare-covered Part A stay. The policy also stated the form should be hand-delivered if possible, signed and dated by the resident or representative, and a copy given to them. For one resident, the Medicare Part A stay began on 11/19/25 and the last covered day was 11/28/25, but no NOMNC was provided to the resident or representative and there was no evidence they were aware of appeal rights; the resident discharged home on 11/28/25. For a second resident, the Medicare Part A stay began on 8/20/25 and the last covered day was 9/3/25, but again no NOMNC was provided and there was no evidence the resident or representative was aware of appeal rights. The Nursing Home Administrator verified that no NOMNC had been issued for either resident and identified the Social Worker as responsible for issuing the form; the Social Worker confirmed the forms were not issued and appeal rights were not communicated.
Failure to Monitor Effectiveness of Trazodone for Insomnia
Penalty
Summary
The facility did not ensure the effectiveness of psychotropic medication was assessed for one resident, who was prescribed trazodone for insomnia. The resident had diagnoses including neurocognitive disorder with Lewy bodies, insomnia, anxiety, psychosis, and conduct disorder, and was receiving hospice care with a guardian for healthcare decisions. The facility's Sleep Disorders-Clinical Protocol stated that nursing staff should describe sleep disturbance in detail, identify possible causes, and monitor the resident's progress toward improving sleep, while the Psychotropic Medication Use policy required adequate monitoring for efficacy and adverse consequences. The resident had an order for trazodone 100 mg at bedtime for insomnia, and medical provider documentation noted increased insomnia and anxiety. However, the resident's medical record did not contain a sleep assessment or a care plan for insomnia. During interview, the ADON verified that the resident received trazodone but did not have a sleep assessment to monitor the effectiveness of the medication.
Failure to Verify Out-of-State Background Check for Agency CNA
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited because the facility did not follow its abuse policy for one CNA-R reviewed for caregiver background checks. CNA-R was hired through a staffing agency and began working shifts at the facility starting on 7/9/25. The facility reviewed 8 staff records and found that CNA-R's Background Information Disclosure form, dated 4/24/23, listed a Louisiana home address, showing the CNA had lived outside Wisconsin within 3 years of hire. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, required background checks and stated the facility would not knowingly employ or engage anyone with findings related to abuse, neglect, exploitation, mistreatment, or misappropriation. On 12/4/25, the surveyor asked the NHA for CNA-R's out-of-state background check, but it was not available through the staffing agency's website. The NHA stated the staffing agency obtained the background check information and that the facility trusted the agency to complete a thorough background check before hire, but the out-of-state background check had not been received when requested.
PASRR Screening Not Updated for Two Residents
Penalty
Summary
PASRR requirements were not met for 2 residents. One resident was admitted with diagnoses including generalized epilepsy and epileptic syndromes, but the facility’s PASRR Level I Screen dated 11/7/25 did not include epilepsy, and no PASRR Level II referral was submitted when the diagnosis was identified. The resident’s record also showed a hospital discharge summary documenting a witnessed generalized tonic-clonic seizure lasting about 1.5 minutes, treatment with 2 mg of Ativan, and a remote seizure history going back 20 years. The resident’s MDS assessment showed intact cognition with a BIMS score of 15 out of 15. A second resident was admitted without a diagnosis of mental illness and was not on psychotropic medication at admission, but later received medications for psychosis, anxiety, depression, insomnia, and conduct disorder, including lorazepam, mirtazapine, trazodone, and prior olanzapine and quetiapine. Despite these changes in condition and treatment, the facility did not complete a new PASRR Level I Screen or submit a PASRR Level II referral. The resident also had diagnoses including neurocognitive disorder with Lewy bodies, insomnia, anxiety, psychosis, and conduct disorder, and received hospice care with a guardian for healthcare decisions.
Inadequate Nail Care for Two Residents
Penalty
Summary
The facility did not ensure nail care was provided for 2 residents who were unable to complete activities of daily living independently. The facility’s policy for care of fingernails/toenails, revised February 2018, stated nail care includes daily cleaning and regular trimming, and that proper nail care helps prevent skin problems around the nail bed and keeps nails trimmed and smooth. The deficiency was identified through observation, staff interview, and record review for two sampled residents, R7 and R8. R7 had diagnoses including Alzheimer’s disease, brain bleed, fractures of the right femur and second thoracic vertebra with routine healing, and cognitive communication deficit. R7’s MDS indicated R7 could not complete the assessment, and the care plan noted ADLs had deteriorated related to dementia with staff to assist using cueing or reminders. Surveyors observed R7’s fingernails to be long, jagged, and chipped, with dirt under some nails; the right middle fingernail and left thumb, index, and middle fingernails were greater than 1/4 inch long. When the DON observed R7, she indicated it was time for a manicure and asked R7 to wash hands. R8 had diagnoses including dementia, affective mood disorder, anxiety, stroke, convulsions, psychosis, and insomnia, and was rarely or never understood on MDS with a guardian. R8’s care plan also noted deteriorated ADL ability and staff assistance with ADLs. Surveyors observed R8’s fingernails to be jagged, with dirt under the left middle fingernail, and the DON did not acknowledge the jagged nails or dirt, instead indicating the hands should be washed. The ADON stated residents’ fingernails should be short, clean, and not jagged, and that the facility promotes daily nail care if required, otherwise CNAs trim and clean fingernails on shower days.
Restorative ROM Care Not Consistently Provided
Penalty
Summary
The facility did not ensure restorative care was consistently provided for a resident with limited ROM and a functional restorative program. The resident had diagnoses including stroke, foot drop, epilepsy, vascular dementia with agitation, cognitive communication deficit, anxiety, depression, malignant neoplasm of connective and soft tissue of the left lower limb, and muscle wasting and atrophy of the left thigh and right lower leg. The resident’s care plan called for PT/OT strengthening as needed and a functional restorative program that included passive stretches and PROM for the upper and lower extremities 1 to 2 times per day, preferably during ADLs or when laid down, with assistance of 2 and use of the documents in the closet for guidance. Surveyor observation and interviews showed the restorative program was not consistently carried out and documentation was lacking. The resident was observed unable to move any extremities independently, the closet did not contain the restorative exercise documents, and a CNA stated stretches were done but exercises were not. A PTA verified the resident was supposed to receive PROM, but was uncertain how often restorative aide visits occurred and stated CNAs were not instructed to do PROM. The NHA stated the facility did not have a CNA scheduled as a restorative aide, used agency staff, was uncertain whether PROM was being done, and confirmed there was not sufficient charting for PROM and that the documentation in the resident’s record was scarce and lacking.
Medication Administration and Self-Administration Deficiencies
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of each resident when staff did not administer medications in accordance with physician orders for one resident and left medications at the bedside for another resident who was not approved to self-administer. The facility’s policies stated that medications should be reordered electronically or by fax when possible and that a resident may only self-administer medications after the IDT determines which medications may be safely self-administered and documents the assessment in the medical record. One resident was admitted with diagnoses including a closed tibia fracture, diabetes mellitus with diabetic polyneuropathy, and pain, and had a BIMS score of 1 out of 15 indicating severely impaired cognition. The resident had orders for a weekly buprenorphine 10 mcg/hour transdermal patch and guaifenesin 600 mg ER twice daily. During observation, the RN could not locate the ordered guaifenesin 600 mg ER tablets and could not find the buprenorphine patch in the medication cart. The RN stated the patch would be looked for later and that the resident would keep the current patch on until the new one arrived. The next day, the guaifenesin 600 mg ER tablet was found in the cart and administered, and the buprenorphine patch had been received by the night shift nurse but was not administered on the scheduled day. The MAR reflected the medication was not given, and the order was later discontinued and re-entered. A second resident had diagnoses including colectomy with colostomy, stage 4 sacral and heel ulcers, quadriplegia due to C5-C7 complete spinal cord injury, diabetes, COPD, and depression, and had a BIMS score of 13 out of 15. The resident’s self-administration assessment indicated the resident did not want to self-administer medications and was not appropriate to do so because the resident could not open containers, pour pills, punch out medication, properly dispense certain dosage forms, or swallow medication without altering the form. Despite this, staff were observed dispensing medications into a cup and handing them to the resident at the bedside, where the resident took some medication and left other tablets in the cup on the bedside table. The resident had no order or care plan for self-administration, and the ADON verified that medication should not have been left at the bedside.
Failure to Monitor Adverse Reactions to Prophylactic Antibiotic
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met when the facility did not monitor a resident for adverse reactions to a high-risk medication. R19 was prescribed cefdinir, an antibiotic ordered for prophylactic measures due to a history of UTIs, and the order had no end date. The resident was admitted with diagnoses including history of UTI, urinary retention, infection and inflammatory reaction due to an indwelling urethral catheter, and sepsis. R19's MDS assessment dated 11/7/25 showed a BIMS score of 14 out of 15, indicating intact cognition. The facility's High Risk Medications policy stated that antibiotics are considered high-risk medications and that the resident's plan of care shall alert staff to monitor for adverse consequences of any high-risk medications given. Review of R19's medical record from 12/1/25 to 12/4/25 did not show monitoring for adverse reactions to the prophylactic antibiotic. On 12/3/25 at 2:13 PM, the Regional Nurse Consultant confirmed that adverse reaction monitoring was not implemented for R19's antibiotic and stated it should have been implemented when the resident started the medication.
Failure to Assess Residents for PFA Feeding Assistance
Penalty
Summary
The facility did not ensure that two residents, both with dysphagia and severe cognitive impairment, were assessed for appropriateness for the Paid Feeding Assistant (PFA) program before PFAs assisted them with dining. The facility’s Dining Assistant policy required a Registered Nurse assessment to determine whether a resident had complicated swallowing or feeding concerns and stated that only residents without such concerns could be physically assisted by Dining Assistants under licensed nurse supervision. However, the records for both residents did not show an interdisciplinary assessment or evaluation documenting whether they were appropriate for PFA assistance. One resident had diagnoses including dementia with behavioral disturbance, history of cerebral infarction, protein-calorie malnutrition, and psychosis, and a speech-language pathology (SLP) evaluation documented oropharyngeal dysphagia. The resident’s MDS showed severely impaired cognition, and the resident had a guardian for healthcare decisions. The SLP evaluation and discharge summary described the resident as needing feeding assistance, being at risk for aspiration due to dependence on staff for feeding, and requiring specific mealtime strategies such as decreased distractions, upright positioning, slow rate, small bites, alternating liquids and solids, and cueing. Despite this, two trained PFAs reported assisting the resident with meals, and one later clarified that the assistance was cueing rather than physical feeding. The second resident had diagnoses including severe dementia with anxiety, pneumonia, acute cough, and oropharyngeal dysphagia, with an MDS BIMS score of 00 indicating severely impaired cognition and an activated POAHC. The resident’s SLP evaluation documented difficulty swallowing, choking on medications, coughing on liquids, poor liquid intake, and risk for choking, aspiration, and inadequate intake. The SLP discharge recommendations included upright positioning, slow rate, small bites, feeding assistance if sleepy, and alternating liquids and solids. A trained PFA reported assisting this resident with meals and later clarified that the assistance involved cueing during one-to-one supervision, but the resident’s record and care plan did not show an assessment approving PFA involvement.
Failure to Use EBP and Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for one resident with a Foley catheter. The resident had diagnoses including an unspecified displaced fracture of the first cervical vertebra, cervical discitis, MSSA infection, type 2 diabetes, and pain. The resident’s MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition, and the resident had a urinary catheter. During observation, two staff transferred the resident from a wheelchair to bed without wearing gowns. An agency CNA then entered the room, donned gloves, emptied the catheter bag, cleansed the drainage port with an alcohol wipe, and disposed of the urine without wearing a gown. The CNA completed hand hygiene after removing gloves. Later, the CNA re-entered the room, donned a gown and gloves, completed catheter and peri-care, removed gloves, then put on clean gloves and applied a clean brief without completing hand hygiene between glove removal and donning clean gloves. The CNA stated that a gown was not needed if the resident did not have a wound and said gowns and gloves were only needed for residents with a Foley catheter, TB, or influenza. The CNA also stated no infection control education had been provided by the facility and that the agency app directed staff to review a binder at the facility, but the CNA had not seen such a binder. The DON stated the resident should have been on enhanced barrier precautions because of the Foley catheter and acknowledged there was no EBP sign on or near the door. The DON also stated transferring a resident in the room was not considered close contact requiring EBP, while other EBP signs in the facility indicated gowns and gloves should be worn during transfers.
Failure to Provide Appropriate Dementia Care and Use of Unauthorized Restraint
Penalty
Summary
A resident with a diagnosis of Alzheimer's disease and other forms of dementia was admitted for a short-term respite stay. The resident had a known history of wandering but no prior physically aggressive behavior. On the evening in question, staff attempted to assist the resident with bedtime care, which the resident resisted, stating that only their spouse performed such care. The resident became increasingly agitated, expressed a desire to leave the facility, and attempted to exit through multiple doors. In response to the resident's attempts to leave, multiple staff members pursued the resident throughout the facility, physically blocked exit doors from both inside and outside, and put hands on the resident to prevent elopement. These actions escalated the resident's agitation and resulted in the resident becoming physically aggressive, injuring several staff members. Law enforcement was called, and upon arrival, the resident reported feeling attacked by numerous individuals. Staff interviews and record reviews revealed that staff did not follow the facility's own policies and training regarding the management of agitated or wandering residents, which emphasize the use of least restrictive measures, avoiding physical restraint, and not blocking exits. The facility's care plan for the resident included specific interventions for wandering and agitation, such as approaching from the front, avoiding overstimulation, providing reassurance, and maintaining a calm environment. However, these interventions were not followed during the incident. Staff actions, including physically restraining the resident and blocking exits, were inconsistent with both the care plan and facility policies. Post-incident interviews indicated that some staff were not adequately trained on managing severe agitation or elopement, and there was a lack of immediate post-incident education for all involved staff.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported to the State Agency (SA) for one resident who was admitted for a 5-day respite stay and had a diagnosis of Alzheimer's disease, among other conditions. On the evening in question, the resident became agitated and attempted to leave the facility through multiple doors. Staff responded by holding the doors shut and physically restraining the resident to prevent elopement, including holding the resident in a chair. Law enforcement was called to assist, and a police report documented that the resident alleged being attacked by numerous individuals. The police also observed staff who appeared distressed and noted that staff were holding the resident in a chair upon arrival. Despite these events and the facility's own policy requiring immediate reporting of suspected abuse to the SA, the Nursing Home Administrator (NHA) did not report the incident, citing the absence of resident injuries and attributing the situation to behavioral issues. The NHA also did not conduct interviews with staff involved in the incident and relied solely on statements obtained by law enforcement. Additionally, the NHA had not reviewed all relevant documentation, including the police and crisis reports that contained allegations of abuse. The failure to report the incident to the SA constituted a deficiency in the facility's abuse reporting procedures.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident admitted for a 5-day respite stay with diagnoses including Alzheimer's disease, dementia, and anxiety disorder. On the evening of the incident, the resident became agitated and attempted to leave the facility through multiple exits. Staff responded by holding doors shut and physically restraining the resident in a chair to prevent elopement. A crisis report and police report documented that staff held the resident in a chair and that the resident later stated to police that they had been attacked by numerous individuals. The facility did not ensure that all staff involved in the incident were interviewed as part of the investigation. Several staff members who were present or directly involved, including CNAs and an LPN, were not asked for statements by facility administration. Some staff indicated they were not approached for statements by the facility, and their accounts were not included in the facility's investigation documentation. Additionally, the facility did not obtain or review the police report or county crisis documentation, both of which contained relevant information about the incident and the resident's allegations. The facility's policy required that all allegations of abuse be thoroughly investigated, including interviewing all witnesses and reviewing all events leading up to the incident. However, the investigation was incomplete, as key staff interviews were not conducted, and external reports were not obtained or reviewed. This failure to follow policy resulted in an incomplete investigation of the abuse allegation involving the resident.
Failure to Report Resident-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure the timely reporting of a reasonable suspicion of a crime, as required by section 1150B of the Act. Specifically, the facility's policy on reporting abuse, neglect, exploitation, or misappropriation did not include examples of crimes that should be reported, such as assault and battery, nor did it indicate that the facility had consulted with local law enforcement to clarify reporting requirements. On one occasion, a resident struck another resident in the face, an incident witnessed by a medication technician. Despite the policy stating that law enforcement officials should be notified, the facility did not report the incident to local law enforcement. Both residents involved in the incident had severe cognitive impairment, as indicated by their low BIMS scores and diagnoses of dementia, and were unable to recall the event during subsequent interviews. The administrator stated that the incident was not considered malicious and, based on the residents' inability to recount the event, decided not to report the abuse to law enforcement. The facility did conduct internal assessments and interviews following the incident, but the required external notification was not made.
Failure to Maintain Safe and Sanitary Facility Entrance
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment for residents in the area outside the building. Observations made by the surveyor revealed that the front of the facility was unkempt, with long weeds present along the building, under residents' windows, along fencing, and around trees. The area also contained an open dumpster with garbage bags, lacking a complete privacy fence on one side facing the main parking lot and public roadway. Additional items observed included two plastic chairs, one holding dried cardboard, a garbage can labeled for laundry without a lid and containing items, and a pile of dry dirt and landscaping bark along the path to the front doors. Three garbage cans were present at the entrance, one with a stained lid, and exposed wires were seen where a doorbell was missing near the main entrance. During staff interviews, it was confirmed that the front doors, which were supposed to be locked during the night shift for safety, were not locked within the required timeframe. The Nursing Home Administrator acknowledged that staff were aware of the need to lock the doors, but the process for auditing door security had not yet been implemented. The administrator also confirmed that the dumpster should have been closed. These conditions had the potential to affect more than 4 of the 28 residents residing in the facility.
Failure to Ensure Proper Wound Vac Management and Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including quadriplegia, diabetes, and a history of osteomyelitis, did not receive appropriate care and services to prevent pressure injuries and promote healing. The resident had a wound vac (negative pressure wound therapy) placed by a wound provider, with orders for dressing changes per protocol. On one occasion, staff reported to the Director of Nursing (DON) that the wound vac dressing was not adhered properly, but the DON did not assess the dressing or ensure the wound vac was functioning as intended. Certified Nursing Assistants (CNAs) observed that the dressing was bunched up and not suctioning, and communicated this to the DON, who stated the dressing was fine and did not further assess the situation. Subsequent nursing assessments documented worsening maceration and a deteriorating wound condition, with the wound vac dressing being replaced and noted to be running correctly at one point. However, later documentation and interviews revealed that the wound vac dressing was not intact, the foam was not suctioning, and there was a strong odor at the wound site. The resident developed a low-grade fever and redness, and alternative wound care was provided after the wound vac was removed. Staff interviews indicated that some nurses were uncomfortable with wound vac dressing changes, and alternative dressing orders were provided for such situations. Despite these measures, there was a lack of consistent assessment and intervention when concerns about the wound vac's function were raised. The facility's policies required ongoing review of interventions and adherence to clinical guidelines for negative pressure wound therapy. However, the failure to promptly assess and address the malfunctioning wound vac, as well as the lack of comprehensive staff education on wound vac management, contributed to the resident not receiving the necessary care to prevent further deterioration of the pressure injury.
Failure to Prevent and Investigate Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance to prevent accidents and did not conduct a thorough investigation following a resident's fall. The resident, who had a history of cervical laminectomy, Parkinson's disease, diabetes, and recent vertigo, fell out of bed after a CNA left the room to assist another resident. The resident was unable to reach the call light and, after calling for help without response, used the phone to call 911. Law enforcement and EMS responded, assisted the resident, and transported them to the emergency department for evaluation. The facility's policies required staff to identify interventions based on resident-specific risks and to conduct a root cause analysis within 24 hours of a fall, including documentation of the circumstances, assessment data, and interviews. However, the event report for the incident lacked nursing documentation, staff or resident interviews, and a root cause analysis. There was also no documentation of the resident's condition immediately after the fall, including the status of the surgical neck wound or a description of the initial fall after returning from the bathroom. Interviews with facility staff confirmed that the investigation was incomplete and did not include the required elements. The DON could not recall the root cause analysis or the reason for the fall, and the event report was closed without these critical components. The resident's medical record and event report did not meet the facility's own policy requirements for post-fall assessment and documentation.
Missed IV Antibiotic Dose Due to Failure to Change Cartridge
Penalty
Summary
A resident with multiple diagnoses, including osteomyelitis of the thoracic vertebra, was admitted to the facility and prescribed a continuous 24-hour intravenous (IV) antibiotic (cefazolin) administered via a CADD pump. The resident was cognitively intact and made their own medical decisions. On one occasion, the scheduled change of the antibiotic cartridge was not performed as ordered, resulting in the resident missing a dose of the IV antibiotic. The missed dose was confirmed by both the resident and multiple staff members, who noted that the cartridge was found dry and unchanged the following day, and an unused cartridge was left over and subsequently discarded. The Director of Nursing (DON) was responsible for the shift when the cartridge should have been changed but did not perform the task. The medication administration record indicated the dose was given, but staff interviews and the presence of an unused cartridge confirmed the dose was missed. The incident was reported to the Nursing Home Administrator (NHA), who initially did not investigate further based on the DON's assurance that the dose was not missed. The deficiency was identified through staff and resident interviews, as well as review of medical records and medication supplies.
Failure to Document DON Assessment in Resident Medical Record
Penalty
Summary
A deficiency occurred when the Director of Nursing (DON) failed to document an assessment and observation of a resident with severe cognitive impairment and multiple complex medical diagnoses, including pneumonitis, dysphagia, and respiratory failure. The facility's policy required that all services, changes in condition, and objective observations be documented in the resident's medical record to ensure complete and accurate communication among the interdisciplinary team. On the date in question, therapy staff expressed concerns about the resident's respiratory status and swelling, prompting the DON to assess the resident. The DON verbally reported the assessment findings to the registered nurse (RN) but did not enter any documentation of the assessment or observations into the resident's medical record. Subsequent interviews confirmed that the DON acknowledged the lack of documentation and that the assessment was only communicated verbally. The resident's medical record was missing this critical information, despite the facility's policy and the need for accurate records to reflect changes in the resident's condition. The omission was identified during a surveyor's review of the medical record and staff interviews, which also revealed that the resident was later sent to the hospital and passed away. The failure to document the DON's assessment constituted a lack of complete and accurate medical records for the resident.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to follow proper infection prevention and control protocols during wound care for a resident with multiple complex medical conditions, including traumatic spinal cord injury, diabetes, quadriplegia, and an ESBL-resistant infection. During the wound care procedure, the RN did not perform hand hygiene between glove changes and wore two pairs of gloves simultaneously, contrary to facility policy. Additionally, the RN used scissors that had been used to cut a soiled dressing to then cut a clean dressing, without sanitizing the scissors in between uses. These actions were observed during wound care on the resident's left heel and buttock, both of which had significant wounds, including a stage 4 pressure injury. Facility policies required hand hygiene immediately after glove removal and the use of clean, sanitized equipment during wound care. The RN acknowledged not performing hand hygiene between glove changes and not sanitizing the scissors before using them on a clean dressing. The Assistant Director of Nursing confirmed that the RN's actions were not in accordance with facility protocols, specifically regarding glove use and the need for clean equipment during wound care.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure a safe environment free from abuse for two residents, both of whom had dementia and activated Powers of Attorney for Healthcare. One resident had a documented history of sexually inappropriate behavior, verbal and physical aggression, and wandering. Despite multiple incidents where this resident made sexual comments, was verbally and physically aggressive, and entered other residents' rooms, the facility did not consistently implement or revise interventions to address these behaviors or ensure the safety of other residents. Progress notes documented several incidents, including inappropriate sexual comments and altercations with other residents, but there was a lack of corresponding care plan updates or incident reports for these events. On one occasion, a resident was observed touching another cognitively impaired resident's breasts under her shirt. The incident was witnessed by another resident, who intervened and notified staff. Both the victim and the perpetrator had severe cognitive impairment and activated POAHCs. Prior to this event, the resident with a history of inappropriate behavior had previously been involved in similar incidents, including a prior sexual interaction with another resident and multiple episodes of aggression and boundary violations. Staff interviews revealed that these behaviors were known among staff, but documentation and communication regarding specific incidents and follow-up actions were inconsistent or lacking. The facility's policies required prompt reporting, investigation, and care plan revision following resident-to-resident altercations, especially those involving abuse or aggressive behavior. However, the facility was unable to provide evidence of investigations, incident reports, or care plan revisions for several documented incidents involving the resident with a history of inappropriate behavior. Staff and administration interviews confirmed gaps in communication, documentation, and follow-up, contributing to the failure to prevent the sexual abuse of a cognitively impaired resident by another resident with known high-risk behaviors.
Removal Plan
- Placed R2 on 1:1 supervision.
- Reviewed medical records and interviewed staff to identify other residents who may exhibit high-risk behavior.
- Developed care plans for residents identified with the potential for high-risk behavior.
- Reviewed the Abuse policy and playbook.
- Completed staff education on resident rights, abuse, reporting responsibilities, and willful/intentional acts.
- Initiated audits to ensure compliance.
Failure to Timely Report Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse involving two residents, as required by both facility policy and regulatory standards. Specifically, one resident with dementia and moderate cognitive impairment exhibited sexually inappropriate, verbally, and physically aggressive behaviors toward other residents on multiple occasions. Another incident involved a verbal altercation between this resident and another resident with no cognitive impairment. Despite these events, there was no evidence that the facility reported the allegations of abuse to the State Agency as required. Documentation in the medical records indicated that the resident with dementia made inappropriate sexual and combative comments to other residents and was involved in aggressive behavior on several dates. Staff documented these behaviors in progress notes but did not specify the exact nature of the comments or identify the recipients. Additionally, a verbal altercation between the two residents was documented, and staff intervened to separate them. However, there was no documentation of these incidents being reported to facility leadership or the State Agency, nor was there evidence of an investigation or follow-up as required by facility policy. Interviews with staff revealed uncertainty about whether the incidents were reported, and the Director of Nursing was unable to provide documentation of any investigation or reporting for the incidents in question. The Nursing Home Administrator, who was not employed at the time of the initial incidents, confirmed that the facility's policies require such events to be reported and that staff should notify leadership when incidents occur. The lack of timely reporting and investigation of these incidents constituted a deficiency in the facility's abuse reporting practices.
Failure to Investigate Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents, as required by its own policies and regulatory standards. Progress notes documented that one resident, who had dementia with psychosis and moderate cognitive impairment, exhibited sexually inappropriate, verbally, and physically aggressive behaviors toward other residents on multiple occasions. Another incident involved a verbal altercation between this resident and another resident with a history of stroke and no cognitive impairment, after the first resident took the other's hat, leading to an argument that staff had to intervene to stop. Despite these documented incidents, the facility was unable to provide evidence of any investigations into the alleged abuse or altercations. The Director of Nursing (DON) acknowledged awareness of some of the incidents but could not provide details about the specific behaviors, the individuals involved, or any investigative actions taken. There was also no documentation to show that the incidents were reviewed or that appropriate actions were implemented in response to the behaviors. The facility's policies require that all allegations of abuse and resident-to-resident altercations be promptly reported, thoroughly investigated, and documented, with findings reported to appropriate leadership. However, the lack of investigation records and incomplete knowledge of the incidents by facility leadership demonstrate that these procedures were not followed for the incidents in question.
Failure to Timely Update Fall Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to ensure that care plans for three residents at high risk for falls were reviewed, revised, or updated in a timely manner following fall incidents, as required by facility policy. For one resident with severe cognitive impairment and multiple diagnoses, including chronic pain syndrome and dementia, the care plan was not updated after two falls, one of which resulted in significant injuries including a femur fracture and scalp laceration. Although staff reportedly implemented new interventions such as placing a fall mat and lowering the bed, these changes were not documented in the resident's care plan. Another resident, also with severe cognitive impairment and a history of falls, experienced multiple falls over several months. The care plan interventions were not consistently updated after each fall. In some cases, interventions were added to the care plan days or weeks after the fall occurred, and in other cases, interventions were already listed in the care plan prior to the fall, indicating a lack of timely review and revision. Documentation did not always reflect the implementation of new or different interventions following each incident. A third resident with dementia and a history of falls also had multiple falls, with care plan interventions not being updated promptly. For some falls, interventions were documented as being added to the care plan weeks after the incident, and in other cases, no new interventions were documented at all. Interviews with facility staff, including the DON and LPN, confirmed that changes to care plans should be documented at the time interventions are implemented, but this was not consistently done for these residents.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident altercations involving four residents. On multiple occasions, a resident with severe cognitive impairment engaged in aggressive behavior towards other residents. These incidents included rolling a wheelchair into another resident's foot, yelling, and physical altercations. Despite being placed on 15-minute checks and later 1:1 supervision, the resident continued to have altercations, indicating a lack of effective supervision. The facility's staff did not consistently implement the required interventions for the resident. Although the resident was supposed to be on 1:1 supervision when outside their room, this was not always provided. During one incident, the resident was not supervised, leading to a physical altercation with another resident. Additionally, the motion sensor and audio monitoring devices intended to assist in supervision were not properly managed, as staff were unaware of their locations or how to use them effectively. Interviews with staff and the nursing home administrator revealed gaps in communication and training regarding the supervision and monitoring of the resident. The education provided to staff about the monitoring interventions was insufficient, with only a small portion of the nursing staff having signed the education sheet. Furthermore, there was no specific assignment of staff to provide 1:1 supervision, leaving it to the discretion of the nurse on duty, which contributed to the failure in supervision.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report an incident of resident-to-resident altercation to the State Agency as required by their Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy. The incident involved two residents, R1 and R5, who were involved in a physical altercation on 9/7/24. R1, who had severe cognitive impairment and required 1:1 supervision, was not being supervised at the time of the incident. R5, who had moderate cognitive impairment, became upset with R1 and a physical altercation ensued. The altercation was not reported to the State Agency because neither resident incurred physical injuries. R1 was admitted to the facility with diagnoses including a fall with a fracture and dementia, and had a BIMS score indicating severe cognitive impairment. R5 was admitted with diagnoses including dementia and depression, with a BIMS score indicating moderate cognitive impairment. The facility's policy requires immediate reporting of suspected abuse to the administrator and state authorities, but this was not followed. The Nursing Home Administrator confirmed that the incident was not reported due to the absence of physical injuries.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, which had the potential to affect all 30 residents. During an initial tour of the kitchen, the surveyor observed that cooling logs were not completed for leftover foods, including meatballs, chili, hard-boiled eggs, and cooked carrots. These items were not listed on the cooling log, and the Dietary Manager (DM) acknowledged that they should have been discarded. The facility's policy requires logging food temperatures for cooling foods within acceptable times, but this was not adhered to. Additionally, the surveyor noted cleanliness issues in the resident snack refrigerator, which contained dry sticky debris and layers of cardboard food packaging stuck to the shelves. The Nursing Home Administrator (NHA) stated that dietary staff were responsible for cleaning the refrigerator, but there was no cleaning log available, and the NHA was unaware of the last cleaning date. The DM confirmed the absence of a cleaning log and stated that the refrigerator had been cleaned within the last month. The facility also failed to monitor and document food holding temperatures. The Dietary Manager in Training (DMT) was observed serving lunch and checking food temperatures only once, without verifying holding temperatures before or after serving. Furthermore, food items for resident consumption were not labeled with open or expiration dates, and some were beyond the labeled discard date. The surveyor found icy pops and cottage cheese without proper labeling, and the DM could not confirm if the icy pops were for resident consumption.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which is crucial for preventing the development and transmission of communicable diseases and infections. The facility's Infection Control Manual, dated 2019, requires the creation of monthly and quarterly infection summary reports, but the facility did not maintain these reports. This was confirmed by the Director of Nursing (DON), who also serves as the Infection Preventionist, during an interview with the surveyor. The absence of these reports indicates a lack of ongoing infection surveillance, which is a fundamental component of an effective infection control program. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for three residents with a history of multi-drug resistant organisms (MDROs). These residents, identified as having conditions such as MRSA infection and ESBL resistance, did not have orders for EBP, nor were there signs posted in their rooms indicating the need for such precautions. The DON confirmed that these residents were not on EBP, despite having indwelling lines and MDRO colonization, which are conditions that typically require such precautions. This oversight in implementing EBP further highlights the deficiencies in the facility's infection control practices.
Facility Fails to Maintain Clean and Homelike Environment Due to Persistent Urine Odor
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for its residents, as evidenced by a persistent urine odor noted by surveyors during observations on two consecutive days. The odor was detected upon entering the facility, in the dining room during lunch service, and in resident hallways and common areas, with the strongest odor on the 100 wing. Interviews with housekeeping staff confirmed the presence of the odor, and they suggested that the lack of air fresheners and issues with caulk around toilets might be contributing factors. Additionally, social services staff indicated that unsealed resident trash cans might also be contributing to the odor, and staff had been instructed to empty them more frequently. A resident, identified as R15, and their family member both confirmed the presence of the urine odor, with the family member noting that the 100 wing had a stronger odor than the 200 wing. R15, who had intact cognition as per their most recent Minimum Data Set assessment, expressed dissatisfaction with the facility's smell. The nursing home administrator also verified the presence of the odor, acknowledging the issue during an interview with the surveyor.
Failure to Investigate Potential Abuse Incidents
Penalty
Summary
The facility failed to thoroughly investigate incidents involving potential abuse for five residents, leading to deficiencies in their abuse prevention program. One resident, with moderate cognitive impairment, was found with an injury of unknown origin, specifically a bruise near the left eye, which was not investigated by the facility. The Regional Director of Operations was unaware of the incident until questioned by the surveyor, and there was no documentation of an investigation, indicating a lapse in the facility's protocol to rule out abuse. In another incident, two residents with severe cognitive impairments were involved in a resident-to-resident altercation, where one resident made contact with the other's face. Although the facility initiated an investigation and placed the residents on 15-minute checks, the investigation was incomplete as it did not include interviews with other staff or residents to ensure no further abuse concerns existed. The current Nursing Home Administrator confirmed that important documentation from the previous administration was missing, contributing to the incomplete investigation. A third incident involved a resident with intact cognition and another with severe cognitive impairment, where the latter attempted to hit the former. The facility did not conduct an investigation into this altercation, and the Regional Director of Operations was not aware of the physical contact involved. The lack of investigation into these incidents highlights a significant deficiency in the facility's ability to protect residents from potential abuse and ensure thorough investigations are conducted.
Deficiencies in ADL Assistance and Shower Provision
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for five residents, as observed by surveyors. Resident 19, who was diagnosed with dementia and failure to thrive, required partial assistance with meals according to their care plan. However, during a meal observation, the resident was not consistently assisted with eating, as the CNA responsible for feeding was attending to multiple residents simultaneously. The CNA did not sit at eye level with Resident 19, which is considered best practice, and the resident did not attempt to eat independently during the observation period. Additionally, the facility did not consistently provide scheduled weekly showers for Residents 15, 4, 6, and 31. Resident 15 reported missing showers due to short staffing, and documentation confirmed the absence of shower records for several weeks. Resident 4 also reported irregular shower schedules, which was corroborated by resident council meeting minutes and grievance forms. Resident 6 experienced similar issues, with documentation showing missed showers over a sixteen-week period. Resident 31, who was discharged, received only one shower in the documented period without any recorded refusals. The Director of Nursing confirmed the lack of documentation indicated showers were not provided and acknowledged the residents' preferences and care plans were not followed. The facility's failure to adhere to care plans and provide necessary assistance and hygiene care highlights deficiencies in staffing and adherence to established care protocols.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to implement its abuse policy by not completing timely and thorough background checks for four out of eight sampled staff members. The facility's policy, revised in April 2021, mandates conducting employee background checks to ensure that no individual with a history of abuse, neglect, exploitation, or related disciplinary actions is employed. However, the facility did not obtain Integrative Background Information System (IBIS) or Department of Justice (DOJ) reports for a Certified Nursing Assistant (CNA)-T and a Dietary Aide (DA)-S. Additionally, the facility obtained the IBIS and DOJ reports for a Physical Therapist (PT)-R only after the individual had already been hired. Furthermore, a background check for CNA-U had not been completed within the last four years, and no IBIS or DOJ reports were provided for this individual. The deficiency was identified during a caregiver program compliance check conducted by a surveyor. The Regional Director of Operations (RDO)-D acknowledged the issue, attributing the missing background check information to the absence of a current Human Resources (HR) Director. The previous HR Director may have discarded some of the necessary documents, and the facility was in the process of recruiting a new HR Director. In the meantime, all background checks were being processed through the company's HR headquarters. The RDO-D recognized the concern and indicated that the issue would be addressed once a new HR Director was hired.
Failure to Address Resident Grievance Due to Phone System Issues
Penalty
Summary
The facility failed to promptly address a grievance raised by a resident, identified as R15, regarding the lack of response to their call light. R15, who has intact cognition as indicated by a BIMS score of 15 out of 15, reported that when staff did not respond to their call light, they contacted a family member, FM-L, to call the facility for assistance. FM-L attempted to contact the facility multiple times but was unable to reach anyone or leave a message due to the absence of a voicemail system. Despite R15 informing the staff about the issue, the facility did not follow up with R15 or FM-L to resolve the grievance in a timely manner. The surveyor's investigation confirmed the communication issues, as calls made to the facility's listed numbers resulted in no answer and no voicemail option. Interviews with the Nursing Home Administrator and Social Services staff verified the facility's phone system problems, including the lack of a separate line for staff and the absence of a voicemail system. The grievance was not documented in the facility's grievance file, indicating a failure to adhere to the grievance policy and promptly resolve the issue.
Failure to Report Abuse and Altercations
Penalty
Summary
The facility failed to report incidents involving potential abuse to the Nursing Home Administrator (NHA) and the State Agency (SA) for three residents. On April 2, 2024, a resident with moderate cognitive impairment was found with a bruise of unknown origin on the left eye area. The facility did not report this injury to the NHA or the SA, and there was no documentation other than what was in the resident's medical record. The Regional Director of Operations (RDO) was unaware of the incident until questioned by the surveyor, indicating a lapse in the facility's reporting protocol. Additionally, on July 20, 2024, a physical altercation occurred between two residents, one with intact cognition and the other with severe cognitive impairment. The altercation involved one resident making fists and hitting the other in the chest. Despite the incident being documented in a nursing progress note, the facility failed to notify the SA or the family member of the resident who was attacked. The RDO was aware of the altercation but not of the physical contact, further highlighting the facility's failure to adhere to its abuse prevention policy.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide a written notification of transfer, including the reason for the transfer, location, appeal rights, and contact information for the State Long-Term Care Ombudsman, for a resident who was transferred to the hospital. The resident, who had intact cognition and no activated Power of Attorney for Health Care, was transferred to the hospital following an unwitnessed fall. However, the medical record did not contain the required written notification or documentation of the reason for the transfer, nor was there evidence that this information was conveyed to the receiving provider. The surveyor's review of the resident's medical record and an event report revealed that the transfer details, such as the reason for the transfer, date and time, mode of transportation, and communication with the receiving provider, were not documented. The resident returned to the facility with a hematoma requiring staples and a diagnosis of a urinary tract infection. Interviews with the Regional Director of Operations and the Director of Nursing confirmed the absence of the required transfer notice and documentation.
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident, identified as R6, who was transferred to the hospital. According to the facility's Bed-Holds and Returns policy, revised in October 2022, all residents or their representatives should receive written information regarding the bed-hold policy at the time of transfer, or within 24 hours if the transfer was an emergency. This notice should include details about the duration of the bed-hold policy, the reserve bed payment policy, and the right to return to the facility. However, R6, who was transferred to the hospital on May 12, 2024, did not receive such a notice, and the facility was unable to locate a copy of the signed bed hold policy. R6 was admitted to the facility with diagnoses including metabolic encephalopathy, diabetes mellitus type 2, chronic kidney disease stage 3, and neuropathic bladder with urinary retention. The Minimum Data Set (MDS) assessment indicated that R6 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Despite this, the facility did not provide the required written bed hold notice upon R6's transfer to the hospital. This deficiency was confirmed during an interview with the Regional Director of Operations, who acknowledged the oversight.
Failure to Complete PASRR Level II Screen for Resident
Penalty
Summary
The facility failed to meet the Pre-Admission Screen and Resident Review (PASRR) requirements for a resident with a history of mental illness or mental disorder. The resident was admitted with diagnoses including dementia, insomnia, and depression, and was prescribed psychotropic medications. Despite these indicators, the PASRR Level I Screen incorrectly marked 'no' for major mental disorder and did not trigger a Level II Screen. The resident's medical record also lacked documentation of a county exemption, which is necessary when a resident remains in the facility for long-term care beyond the initial 30-day exemption period. The deficiency was identified during a survey when the resident's medical record was reviewed, revealing that the facility did not complete a PASRR Level II Screen after the resident stayed beyond 30 days. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed the oversight. The facility's policy requires a Level I PASRR Screen for all admissions and a referral for a Level II Screen if criteria for mental disorder or intellectual disability are met, which was not adhered to in this case.
Failure to Develop Comprehensive Smoking Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident following a smoking assessment. The resident, who was admitted with diagnoses including ataxia, alcohol dependence, nicotine dependence, diabetes, debility, and glaucoma, had a Minimum Data Set (MDS) assessment indicating severely impaired cognition. A smoking risk assessment identified the resident as a potential unsafe smoker with moderate problems in areas such as carelessness with smoking materials, general awareness, and capability to follow the facility's safe smoking policy. Despite these findings, the resident's medical record did not contain a smoking care plan until it was requested by the surveyor. The Director of Nursing (DON) stated that the resident did not smoke upon admission, but when the resident expressed a desire to smoke, a smoking assessment was completed. However, the nurse responsible for the assessment did not follow through with creating a care plan, which was only completed on the day it was requested by the surveyor. This oversight resulted in the facility not having a documented plan to address the resident's smoking needs and risks, as required by their own smoking policy.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in preventing urinary tract infections (UTIs). During an observation, it was noted that the staff did not maintain the catheter drainage bag below the level of the resident's bladder, which is necessary to ensure unobstructed urine flow. The facility's policy, revised in April 2022, clearly states that the drainage bag should be positioned lower than the bladder at all times to prevent urine from flowing back into the bladder. The resident involved, identified as R14, had multiple diagnoses, including quadriplegia, pressure injury, osteomyelitis, neurogenic bowel, diabetes mellitus, ESBL resistance, UTIs, and neuromuscular dysfunction of the bladder. On the day of the observation, the surveyor noted that the catheter drainage bag was placed on the bed at the level of the resident's bladder, preventing urine flow. This was confirmed by both a CNA and an LPN, who acknowledged that the bag should be kept below the bladder level. The Director of Nursing also stated that the bag should not remain at the bladder level for extended periods during care and dressing changes.
Failure to Provide Fluids Between Meals
Penalty
Summary
The facility failed to ensure that a resident, identified as R20, was offered fluid intake between meals, as required by the facility's Resident Hydration and Prevention of Dehydration policy. R20, who was admitted with multiple diagnoses including aphasia, dysphagia, neurocognitive disorder with Lewy body dementia, epilepsy, and Parkinson's disease, was at risk for weight loss and aspiration. The care plan indicated that R20 was on a general diet with nectar-thick liquids. However, during the survey period from July 29 to July 31, 2024, the surveyor observed that R20 did not have thickened liquids available in their room, and staff interviews confirmed that fluids were not provided between breakfast and lunch. The surveyor's interviews with R20's Power of Attorney for Healthcare (POAHC) and Certified Nursing Assistants (CNAs) revealed that unless the POAHC was present, R20 did not receive fluids in the morning. The CNAs confirmed the absence of thickened liquids in R20's room, and the Director of Nursing (DON) stated that staff were expected to provide fluids between meals. Despite these expectations, the facility did not adhere to its policy, resulting in a deficiency in providing adequate hydration to R20.
Failure to Monitor High-Risk Medications
Penalty
Summary
The facility failed to ensure proper monitoring of high-risk medications for two residents, leading to deficiencies in their care plans. Resident 6 was prescribed insulin and bumetanide, but their care plan lacked interventions for monitoring potential side effects or adverse reactions to these medications. This oversight was confirmed by interviews with the LPN and the Director of Nursing, who acknowledged the absence of necessary monitoring interventions in the resident's plan of care. Similarly, Resident 19, who had diagnoses including hypertension, syncope, and dementia, was prescribed apixaban and furosemide. The care plan for this resident did not include monitoring for bleeding or other potential side effects related to apixaban use. Additionally, although there was an order to weigh the resident weekly due to diuretic use, the resident had not been weighed for ten out of the preceding twenty-two weeks. The Director of Nursing confirmed these deficiencies, acknowledging the lack of monitoring for side effects and the failure to adhere to the weekly weighing order.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of psychotropic medications for three residents, leading to a deficiency in medication management. Specifically, residents were prescribed lorazepam, an anti-anxiety medication, on a PRN basis without a documented rationale for its continued use beyond the 14-day limit as required by the facility's policy. The policy mandates that PRN orders for psychotropic medications should not exceed 14 days unless a specific rationale and duration are documented by the prescriber. However, for the residents in question, there was no such documentation, and the orders lacked an end date. Resident 1, diagnosed with conditions including dementia and anxiety disorder, had a PRN order for lorazepam without a rationale for its use beyond 14 days. Similarly, Resident 22, with diagnoses of dementia and anxiety, and Resident 19, with dementia and generalized anxiety disorder, also had PRN orders for lorazepam without the necessary documentation. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed the absence of required documentation and acknowledged that the orders should have included a rationale or been discontinued.
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 23 citations issued within 25 miles in the last 12 months — 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 Montello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Markesan Resident Home | 17.4 mi | ★★★★★ | 4 | 0 |
| Columbia Health Care Center | 20.8 mi | ★★★★★ | 4 | 0 |
| Juliette Manor | 22.6 mi | ★★★★★ | 2 | 0 |
| Randolph Health Services | 24 mi | ★★★★★ | 11 | 0 |
| Whispering Pines Nursing And Rehab, Llc | 24.5 mi | ★★★★★ | 2 | 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.