Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mulder Health Care Facility during CMS and state inspections, most recent first.
A resident who required 1-person assist and a gait belt fell during a shower-room transfer when a CNA did not use the gait belt while moving her toward a wheelchair. The resident struck her head, sustained a skin tear and severe R hip pain, and was sent out emergently with a hip fracture. Interviews showed staff disagreement about transfer expectations, and the resident’s transfer status was not accurately maintained in the care plan.
A resident with lymphoma, anemia, neutropenia, and worsening dysphagia received oral etoposide after oncology had documented that the medication was to be stopped. The MAR showed the chemotherapy was administered despite the stop order, and the resident developed nausea, dizziness, weakness, and worsening swallowing difficulty before being sent to the ER, where he was found to be profoundly more anemic and required a blood transfusion. Facility staff later stated the resident should not have received the medication and that the incoming paperwork had not been reviewed by a nurse.
Antibiotic stewardship program not effectively monitored: The facility did not consistently use culture and sensitivity results or track antibiotic use for several residents treated for UTIs. One resident with recurrent UTIs received antibiotics despite resistant or intermediate results across multiple cultures and later required IV ABX, while another resident was given cefdinir without a C&S being completed. A third resident was treated with ciprofloxacin even though the organism was resistant, and documentation did not show provider education or consultation after the resistant results.
Unsafe Food Storage and Dishware Drying Practices: Surveyor observation and interview found wet dishware, including mugs, cups, and bowls, placed upside down on plastic trays so they could not air dry completely. Surveyor also found food items in the walk-in refrigerator past their use-by dates, and a mixer stored under plastic with food debris on the undercarriage. The RCD and Dietary Mgr stated the dishware should air dry completely and the mixer should have been cleaned before being covered.
The facility failed to maintain an effective infection prevention and control program and did not track residents with potentially infectious symptoms unless they met McGeer's criteria. Residents with UTI symptoms, a runny nose, and urinalysis testing were not included on surveillance line lists, and the IP and RCD stated symptomatic residents were not tracked if they did not meet criteria. In addition, a CNA touched a resident's bed with gloved hands during perineal care and then continued care without removing gloves, performing hand hygiene, or donning clean gloves, which the CNA and DON both acknowledged was not proper practice.
Incomplete bed-hold notices were provided for multiple residents after hospital transfers, with required details missing such as the reason for transfer, the receiving location, appeal rights, Ombudsman contact information, and advocacy resources. One resident with DM2, a BIMS score of 15, and recent hospital transfers also received bed-hold notices that lacked the reason for transfer and financial assistance resources. Staff interviews confirmed the forms were often completed verbally and sent with the resident, while the DON stated the notices should include all required information.
Meals were not consistently served at proper temperatures, and residents reported poor meal quality and service. A surveyor’s test tray showed hot foods served too cool and a cold item served too warm, while staff acknowledged the cart door had been left open and the temperatures were not acceptable. Residents reported cold coffee, cold hot foods, missing menus, and meals that did not match what was listed on meal cards.
The facility did not complete Level II PASARR screenings for three residents after Level 1 screenings with 30-day exemptions, and one short-term resident had no Level II PASRR at all. The residents had diagnoses including dementia, PTSD, bipolar disorder, major depressive disorder, and anxiety, and staff confirmed the Level II screenings were not completed as expected.
The facility failed to complete sleep assessments for two residents receiving melatonin for insomnia/nocturnal calming. One resident had moderate cognitive impairment and was given melatonin at bedtime without a sleep assessment, while another long-term resident had been on melatonin for months with no documented sleep assessment. Staff interviews confirmed the facility monitored sleep hours and side effects on the MAR, but did not perform formal sleep assessments before starting sleep aids.
A facility failed to follow medication orders for two residents. One resident had Eliquis given despite instructions to hold it before a scheduled colonoscopy, and the procedure was cancelled because the blood thinner had been administered. Another resident had losartan increased to 75 mg daily, but the pharmacy did not receive the order and staff continued signing out the higher dose while only 50 mg tablets were being supplied.
A resident with insomnia and moderate cognitive impairment received trazodone for sleep, but the facility did not complete a sleep assessment before starting the medication. The RCD and DON stated the LTC facility monitors side effects and logs sleep hours on the MAR, but does not perform sleep assessments prior to initiating a sleep aide, and the DON confirmed the resident had no sleep assessment.
Failure to Honor Resident Meal Preferences: A resident with TBI and Adjustment Disorder, who was cognitively intact per BIMS, had a meal card indicating Frosted Flakes daily for breakfast but reported he did not receive them unless he asked. The resident said the menus did not match what was served and described the food as atrocious. A CNA confirmed the resident did not get the cereal that morning and had to go to the kitchen to obtain it, despite the meal card preference being known to dietary and nursing staff.
A resident with DM, liver cancer, acute MI, and COPD had an incomplete medical record after a hospital stay and clinic procedure. The chart noted the resident was hospitalized for low O2 saturation and pain management, then later returned after an IR microwave ablation with CT guidance and acute respiratory failure, but the hospital and clinic records were missing from the resident’s file. The RCD could not locate the documents, the DON later produced them, and the Medical Records Clerk said they should have been scanned into the chart.
Multiple cognitively intact residents with conditions such as heart disease, morbid obesity, chronic kidney disease, and prior stroke reported that cash amounts ranging from about $50 to $75 went missing from their wallets and rooms, and each identified a CNA as the suspected individual. These residents described incidents occurring over weeks to months, including one resident awakening to find the CNA taking money from her wallet. Review of the EMR and progress notes for each resident over extended periods showed no documentation of their allegations, despite an abuse prevention policy that defines misappropriation of resident property and states residents have the right to be free from abuse and misappropriation, with ongoing oversight and supervision of staff to ensure policies are implemented.
Surveyors found that the facility did not follow its dietician-approved menus, repeatedly serving meals that omitted or substituted listed items such as French fries, vegetables, bananas, and condiments without appropriate, approved substitutions. Staff reported routinely changing menus based on supply and ordering issues and relying on a whiteboard menu marked as subject to change, while residents stated they were not given the actual menu, were unaware of planned items they would have preferred, and were not informed of alternates. In one case, a resident with dementia, kidney disease, and a care plan for a soft, bite-sized diet at risk for weight loss was served whole bread and whole grapes, received no potatoes, and ate independently without the indirect supervision and texture modifications specified in her orders and care plan.
Dietary staff failed to follow proper food handling practices while preparing and serving meals for all residents. A cook was observed taking temperatures of chili with beans, mashed potatoes, and pureed mixed vegetables while touching the inside of the food containers with a bare hand. A dietary aide was observed touching the inside of lids with bare hands while placing them on bowls of chili with beans and then placing these bowls on resident trays. The cook later acknowledged she was not supposed to touch the inside of food containers when taking temperatures, and the dietary aide reported she did not know if she should touch the inside of lids. The dietary manager confirmed staff were not supposed to touch the inside of containers or lids with bare hands during these tasks.
A resident with dementia, kidney disease, and a wound requiring nutritional support was admitted on a regular chopped, soft and bite-sized diet with thin liquids, ordered weekly weights, bedtime snacks, and ProStat twice daily. The care plan and initial nutritional assessment identified the resident as underweight and at risk for significant weight loss, with instructions to monitor intake and weight trends. However, staff failed to document 10 of 46 meals, did not record any weights after an early post-admission entry despite weekly weight orders, and did not show evidence of follow-up on the resident’s documented weight loss. The DON confirmed that weights and meal intake were not consistently documented, contrary to facility policies requiring regular weight monitoring and recording of meal intake percentages.
A facility failed to remove a CNA from resident care duties after an allegation of abuse was made by a resident, despite policy requiring immediate removal and suspension pending investigation. The resident, who was alert and oriented, reported being treated aggressively and physically grabbed by the CNA, with these actions corroborated by other staff. The CNA continued to work additional shifts and had potential contact with other residents during the ongoing investigation.
A resident with multiple medical conditions was subjected to abusive behavior by a CNA, who spoke in a condescending manner, grabbed the resident's wrist tightly without releasing when asked, and yelled in close proximity to the resident's face. The incident was witnessed by another CNA and an LPN, who observed the resident visibly upset and slight redness on the wrist. The event was reported for investigation.
A resident reported being spoken to in an abusive manner and having her wrist grabbed tightly by a CNA, with multiple staff witnessing the incident and noting the resident's distress. Although the event was promptly reported internally, the facility failed to notify the State Survey Agency within the required 24-hour timeframe, resulting in a deficiency for delayed reporting of alleged abuse.
A resident with significant mobility impairments was transferred to the bathroom using an EZ stand when their right arm was bumped against a door frame by CNA staff. The incident was not reported to the charge nurse or documented in the medical record, despite facility policy requiring immediate reporting and communication of all incidents. The DON confirmed the failure to follow protocol after the resident later reported severe pain.
A resident with multiple complex medical conditions, including dysphagia and chronic kidney disease, did not receive adequate daily fluid intake due to the facility's failure to total and assess fluid intake, monitor for dehydration, perform timely weight checks, and update care plans. This led to significant weight loss and repeated hospitalizations for dehydration and aspiration pneumonia, with staff interviews confirming confusion and lack of accountability for monitoring hydration.
A resident who required extensive assistance for toileting due to recent surgery and mobility limitations requested help to use the bathroom but was told by a CNA to wait based on an incorrect toileting schedule. The resident waited approximately 1 hour and 20 minutes before being assisted, during which time staff did not check on her or provide timely care, despite facility policy requiring person-centered and prompt assistance with ADLs.
A resident with a history of serious health conditions experienced a significant drop in oxygen saturation and pulse rate, requiring immediate physician notification. The facility failed to document or communicate this change to the physician, resulting in a deficiency in care. Despite temporary improvement with oxygen therapy, the lack of proper notification and documentation led to inadequate management of the resident's condition.
A resident with a history of cerebral infarction and hemiplegia suffered second-degree burns from hot soup due to inadequate supervision during meals. The facility failed to adhere to its policy of serving hot liquids at safe temperatures, resulting in immediate jeopardy. Staff interviews revealed inconsistencies in supervision responsibilities and a lack of adherence to temperature guidelines.
A facility failed to thoroughly investigate a resident-to-resident altercation involving a cognitively impaired resident who hit another resident. Despite the facility's policy requiring interviews with all involved persons, only the two residents directly involved were interviewed, as the incident was deemed isolated. This led to a deficiency in the investigation process.
Failure to Use Gait Belt During Shower-Room Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were used to prevent accidents for a resident who required a 1-person assist with transfers and a gait belt. The resident was admitted with diagnoses including osteoporosis, reduced mobility, and a prior displaced humerus fracture with delayed healing. Her MDS indicated she was cognitively intact, and her care plan and transfer status were not accurately maintained before the fall. A physical therapy order documented that all transfers were to be completed with a front wheeled walker and minimum assist of 1, and staff interviews confirmed the resident was an assist of 1. During a shower-room transfer, CNA G assisted the resident while she was standing at a grab bar and preparing to move from the shower area to a wheelchair. CNA G stated she did not apply a gait belt because she was not planning to walk the resident and was only positioning the wheelchair behind her. She also stated she was not holding onto the resident when the resident began falling backward. The resident fell, struck her head on a metal bar, sustained a skin tear to the right arm, and had severe right hip pain with internal rotation of the right leg. EMS was called, and the resident was transported emergently for evaluation. The fall investigation and staff interviews showed conflicting understanding of the resident’s transfer needs and the use of a gait belt. CNA G stated she did not use a gait belt, while RN H stated the resident should have had one applied. Rehab staff stated they expected staff to transfer the resident with a gait belt because she required minimum assist of 1. The facility also failed to preserve the resident’s prior transfer intervention in the care plan when ADON J edited the plan to a Hoyer transfer instead of resolving and adding a new intervention, and leadership interviews showed uncertainty about whether gait belts were required during standing transfers in the shower room.
Significant Medication Error With Oral Chemotherapy
Penalty
Summary
The facility did not ensure that residents were free from significant medication errors for one resident who had been admitted with peripheral T-cell lymphoma, hemophagocytic lymphohistiocytosis, bilateral pulmonary embolism, deep vein thrombosis, chemotherapy-induced neutropenia, anemia, autoimmune hemolytic anemia, malnutrition, and dysphagia. The resident’s hospital discharge paperwork listed oral etoposide with instructions to take it only on day 2 and day 3 of each cycle, and the oncology follow-up note later documented that etoposide was to be stopped because treatment was being delayed due to worsening performance status. Despite the oncology instruction to stop etoposide, the resident received oral etoposide on two subsequent days at the facility. The MAR showed administration of the medication after the stop order, and the medication error report identified the error as an incorrect medication that resulted in the need for treatment or intervention. Facility documentation also showed that the resident had worsening dysphagia, poor oral intake, weakness, nausea, and dizziness around the time the medication was given. After the resident became dizzy and nauseous, the resident was sent to the emergency room. The emergency room record documented that the resident had become profoundly more anemic, with hemoglobin reported at 5.8 compared with over 9 the week prior, and that a unit of blood was given. Facility staff later stated that the resident should not have received etoposide, that the incoming paperwork had not been reviewed by a nurse, and that the facility had not been monitoring for adverse reactions or side effects related to etoposide use in the MAR.
Antibiotic stewardship program not effectively monitored
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, including adherence to evidence-based criteria and accurate tracking of antibiotic use, for three residents reviewed for antibiotic therapy. The facility policy required nursing to monitor the initiation of antibiotics, reassess continued need and choice of antibiotic, review laboratory results, and consult with the practitioner about whether the antibiotic should continue or be adjusted based on findings. Surveyors found that these steps were not consistently followed for residents treated for urinary tract infections (UTIs). For one resident with a history of recurrent UTI, type 1 diabetes, and an ankle fracture, a culture and sensitivity result showed Klebsiella pneumoniae resistant to ciprofloxacin, yet ciprofloxacin was ordered. The record also showed a later UTI episode where the organism had intermediate sensitivity to Augmentin, followed by another episode where the organism was intermediate to Macrobid and then resistant to Macrobid. The resident continued to report urinary symptoms across these episodes and ultimately required IV antibiotics. Documentation did not show that antibiotic stewardship education was provided to the provider during this period. A second resident with osteoporosis, schizophrenia, and dementia was prescribed cefdinir for a UTI, but no culture and sensitivity was completed after the urinalysis. The Facility Event Summary Report indicated the McGeer criteria did not meet criteria for a UTI. A third resident with a femur fracture, diabetes, urinary retention, and obstructive/reflux uropathy had a culture and sensitivity showing Morganella morganii, Pseudomonas aeruginosa, and Enterococcus faecalis, with Morganella morganii and Enterococcus faecalis resistant to ciprofloxacin, yet the resident was treated with ciprofloxacin. A repeat culture again showed Morganella morganii resistant to ciprofloxacin, and the facility was unable to provide documentation showing provider education or consultation occurred after the resistant results.
Unsafe Food Storage and Dishware Drying Practices
Penalty
Summary
Food was not maintained in a safe and sanitary manner during storage and dishware handling. Surveyor observation and interview showed wet dishware, including mugs, cups, and bowls, being placed upside down on plastic trays on the clean side of the dishwasher, creating a seal that prevented the items from air drying completely. Facility policy titled "Dish Machine High Temperature," revised 1/2025, did not include dishwashing procedures, and the FDA Food Code section 4-901.11 was cited as requiring equipment and utensils to air dry after cleaning and sanitizing. Surveyor also observed food in the walk-in refrigerator past the use-by date, including barbeque chicken, sweet and sour sauce, creamed corn, and baked beans. The facility policy titled "Handling of Leftover Food," revised 1/2025, stated leftovers should be covered, labeled, dated, and refrigerated as soon as the tray line is finished, and refrigerated leftovers should be used within 3 to 7 days after opening. During interview, the Regional Clinical Director stated the food should have been discarded on the use-by date if it was not used. In addition, a mixer was observed stored under a plastic covering, and when the covering was lifted, food debris was seen on the undercarriage; the Regional Clinical Director stated the mixer should have been cleaned before being covered.
Infection Control Program and Hand Hygiene Failures
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Facility infection surveillance line lists for April 2026 through May 2026 did not include residents who had signs and symptoms of possible infection. In April 2026, one resident had incontinence and dysuria and had a urinalysis, but was not added to the line list. Another resident had a runny nose and underwent a COVID test and chest x-ray, but was also not included. In May 2026, a resident was tested for a urinary tract infection with urinalysis and was not included on the line list. The Regional Clinical Director and Infection Preventionist stated that residents were only added if they met McGeer's criteria, and that residents who were symptomatic but did not meet criteria were not tracked. The facility's infection control policies did not indicate what type of data should be collected for residents with potentially infectious symptoms. The facility also failed to follow hand hygiene standards during resident care. During observation, a CNA and another CNA provided perineal care to a resident while the CNA touched the resident's bed with gloved hands, then continued care without removing gloves, performing hand hygiene, and donning clean gloves. When interviewed, the CNA stated hand hygiene should be done before and after removing gloves and acknowledged she should have removed her gloves, sanitized her hands, and put on clean gloves after touching the bed and before continuing perineal care. The DON stated staff are expected to sanitize or wash hands when entering and exiting a room, between cares, after removing gloves, and before and after glove use, and agreed the CNA should have changed gloves and performed hand hygiene before continuing care.
Incomplete Bed-Hold Notices and Missing Required Transfer Information
Penalty
Summary
The facility did not ensure that the required contents of the Notice of bed-hold policy and return were provided with bed hold notices for 4 of 4 residents reviewed for hospitalizations. R39 had incomplete bed hold notices for 3/8/26 and 5/26/26, R53 had an incomplete bed hold notice for 6/15/26, and R68 had an incomplete bed hold notice for 6/30/26. These notices did not include required information such as the reason for discharge, the location to which the resident was transferred, appeal rights, Ombudsman contact information, or other Advocacy Agency contact information. R9 was admitted with diagnoses including Diabetes Mellitus Type 2, acquired absence of the right leg below knee, and cellulitis of the right lower limb, and the 6/11/26 Quarterly MDS showed a BIMS score of 15, indicating cognitive intactness. R9 was sent to the hospital on 2/5/26 and 4/8/26, and the bed hold notices did not include the reason for transfer or resources available to assist with the financial aspect of holding the bed. The facility policy titled Bed Hold dated 01/25 did not address what the bed hold notice requirements are. During interview, RN M stated the nurse usually completes the bed hold form verbally and that a transfer form and bed hold form are sent with the resident, and DON B stated the bed hold notices should include all required information and be completely filled out.
Meals Served at Improper Temperatures and Residents Report Cold Food and Coffee
Penalty
Summary
Food and drink were not always served at palatable, attractive, and safe temperatures. During a test tray observation, the surveyor found an insulated cart with the door open while resident lunch trays were inside, and the first room tray was passed from that cart shortly afterward. The test tray temperatures were recorded as spaghetti bake at 109 degrees F, zucchini at 108 degrees F, coffee at 119 degrees F, and cottage cheese at 54 degrees F. The Regional Clinical Director stated the cart door should not have been left open with hot meals inside and acknowledged the hot foods were too cool and the cottage cheese was too warm. Residents also reported concerns about meal temperature and meal service. R79, whose MDS showed severely impaired cognition with a BIMS score of 9, stated she sometimes received scrambled eggs at a cool and undesirable temperature. R33, who had diagnoses including traumatic brain injury and adjustment disorder and a BIMS score of 15, stated the food was atrocious, the menus did not match what was served, he did not consistently receive frosted flakes as listed on his meal card, the coffee was never hot, portion sizes were small, and meals were consistently cold. During Resident Council, residents stated the coffee was always cold, they did not get menus, and toast was served dry unless they asked for butter, by which time the toast was cold. R17, a short-term resident with intact cognition and a BIMS score of 15, stated she never got coffee or tea hot.
PASARR Screening Not Completed for Residents With Mental Health Diagnoses
Penalty
Summary
The facility did not follow through with the PASARR process for 3 of 5 residents reviewed for PASARR screening. R8 and R9 each had a Level 1 PASARR screening completed with a 30-day exemption request, but the facility did not have a Level II PASARR screening completed at the end of the 30-day exemption. R72, a short-term resident, also did not have a Level II PASRR completed. The facility policy stated that Social Services would review each potential resident’s psychosocial and behavioral needs and PASARR information and ensure the referring party obtained a Level 2 PASARR screening when indicated. R8 was admitted with diagnoses including vascular dementia, PTSD, bipolar disorder, and borderline personality disorder, and had an MDS admission assessment showing a BIMS score of 12, indicating moderate cognitive impairment. R9 was admitted with major depressive disorder and had an MDS quarterly assessment showing a BIMS score of 15, indicating cognitive intactness. R72 was admitted with generalized anxiety disorder, major depressive disorder, and bipolar disorder, had a Level 1 PASRR completed with a 30-day exemption, and was prescribed quetiapine. During interviews, Social Services and the Quality Assurance Nurse stated that a Level 2 screening should have been completed at the end of the 30-day exemption for these residents, and the Regional Clinical Director confirmed the Level 2 screenings were not completed for R8, R9, and R72.
Lack of Sleep Assessments for Residents Receiving Melatonin
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for 2 residents reviewed for unnecessary medications. R8, who was admitted with a diagnosis of insomnia and had a BIMS score of 12 indicating moderate cognitive impairment, was receiving melatonin 9 mg at bedtime for nocturnal calming, but no sleep assessment had been completed related to the medication. Surveyor interviews with the Regional Clinical Director and the DON confirmed that the facility monitored side effects and hours of sleep on the MAR, but did not complete sleep assessments before starting a sleep aid. R44, a long-term resident, had an order for melatonin 3 mg every bedtime for nocturnal calming that had been started on 11/4/24, but there was no sleep assessment documented before or during the course of treatment. During interview, RN M stated that if a resident complained of insomnia, staff would check the MAR and care plan for medication and non-pharmacological interventions, but that no formal sleep assessment was completed. The DON also stated that residents were monitored for hours of sleep each shift, and acknowledged that the facility did not complete a sleep assessment prior to starting a sleep aid.
Medication Orders Not Followed for Anticoagulant Hold and Losartan Dose Increase
Penalty
Summary
The facility did not ensure accurate acquiring, receiving, dispensing, and administration of drugs and biologicals for two residents. For one resident with diagnoses including Adjustment Disorder, long-term anticoagulant use, and Central Cord Syndrome at C5, the resident had a colonoscopy scheduled with instructions to hold Eliquis 48 hours before the procedure. The resident’s MAR showed Eliquis was still administered on the days leading up to the procedure, and the colonoscopy was cancelled because the medication had been given. The resident stated the procedure had already been cancelled once before because the bowel prep was ineffective and that he was told the facility had not received the hold order, although he later showed documentation confirming the facility had received the instructions. For the second resident, who had diagnoses including Type 2 Diabetes Mellitus and Hypertensive Heart Disease, a provider order increased losartan from 50 mg to 75 mg daily with blood pressure monitoring. The order was documented in the chart and in the clinic outpatient report, and the pharmacy receipt was confirmed, but the pharmacy did not receive the increase order and continued supplying 50 mg tablets. The MAR reflected that staff signed out 75 mg doses from 6/11/26 through 6/23/26 even though only 50 mg tablets were being provided. During interviews, the DON stated the facility’s process was to receive test instructions, enter them into the MAR, and place them on the 24-hour board, and acknowledged the Eliquis hold order should have been transcribed and followed. The DON also acknowledged the Eliquis administration was a medication error. For the losartan issue, staff and leadership stated the facility may not have sent the order to the correct pharmacy and that staff kept signing out the higher dose while giving the 50 mg tablets. The VP of Clinical Services stated this was a medication error and that the resident only received 50 mg until the pharmacy later brought the medications.
Unnecessary Medication Use: No Sleep Assessment Before Trazodone
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met for one of five residents reviewed for unnecessary medications. Resident R8 was receiving trazodone for insomnia, and the facility did not complete a sleep assessment before starting the medication. R8 was admitted to the facility with a diagnosis of insomnia and had an admission MDS assessment showing a BIMS score of 12, indicating moderate cognitive impairment. R8's physician orders show trazodone 200 mg by mouth at bedtime for insomnia, starting on 4/28/26 and continuing as an open-ended order. The MAR shows R8 received trazodone from 4/28/26 through 7/08/26. The care plan included insomnia with a goal of at least 6 hours of sleep per night and an approach to administer medication per MD order, with sleep study as needed. During interviews, the RCD and DON both stated the facility monitors side effects and logs hours of sleep on the MAR, but does not complete sleep assessments before starting a sleep aide, and the DON confirmed R8 did not have a sleep assessment.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to provide food that accommodated a resident’s stated preference for breakfast items listed on the meal card. The resident was admitted with diagnoses including Traumatic Brain Injury and Adjustment Disorder, and his MDS assessment showed a BIMS score of 15, indicating he was cognitively intact. His meal card listed Frosted Flakes daily for breakfast, but he reported that he did not receive them unless he asked for them, which he found upsetting and frustrating. He also stated that the menus did not match what was served and described the food as atrocious. During observation and interviews, the resident again reported not receiving Frosted Flakes that morning until he told the CNA, who then went to the kitchen and brought them to him. The CNA confirmed the resident did not receive Frosted Flakes that morning and that she had to obtain them from the kitchen, despite acknowledging that the meal card indicated he was to receive Frosted Flakes every morning with breakfast. The Dietary Manager stated that resident preferences are collected during intake, transferred to meal slips, and verbally communicated to staff, and the DON also stated she would expect the resident’s preference for Frosted Flakes to be honored.
Incomplete medical record for resident after hospitalization and clinic procedure
Penalty
Summary
The facility did not maintain a complete medical record for a resident with Type 2 DM, malignant neoplasm of the liver and intrahepatic bile ducts, acute MI, and COPD. The deficiency involved missing documentation related to a change in condition and a hospitalization/clinic visit. The resident’s progress note on 6/10/26 stated the facility received a phone call from the hospital that the resident was being kept overnight due to low oxygen saturation and pain management, that transportation was canceled, and that the resident was currently hospitalized. The note also stated wound measurements were not obtained because of hospitalization, but the resident’s record did not contain notes from that hospital stay or from the clinic visit where the resident had an IR microwave ablation with CT guidance of the liver. The resident returned to the facility on 6/15/26, and the progress note documented discharge back from the hospital with a primary diagnosis of acute respiratory failure after the IR microwave ablation procedure. On 7/6/26 and 7/7/26, the surveyor asked the RCD for information regarding the 6/10/26 clinic visit and hospitalization, and the RCD said she could not locate it in the record and would check with Medical Records. On 7/8/26, the DON provided copies of the clinic and hospital records for the 6/10/26 to 6/15/26 time frame and stated they should have been in the resident’s medical record, but there had been staff turnover in Medical Records. The Medical Records Clerk stated the documentation should have been scanned into the record and was not, and the RCD stated the paperwork either was not brought to facility staff or was not printed and scanned in, but either way it should have been there.
Failure to Protect Cognitively Intact Residents From Misappropriation of Funds by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively intact residents from misappropriation of their money by a staff member, CNA1. One resident reported waking from sleep to find CNA1 in her room taking money from her wallet. This resident had diagnoses including adult failure to thrive and heart disease and had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating she was cognitively intact. Her electronic medical record, including progress notes from early August through mid-December, contained no documentation of her allegation of misappropriation of property. During the facility’s investigation into this initial allegation, three additional cognitively intact residents reported missing money and identified CNA1 as the suspected individual. One resident with morbid obesity and heart disease stated that $55 to $75 was taken from her wallet within the first few weeks after admission; her progress notes over several months contained no entries related to this allegation. Another resident with congestive heart failure and chronic kidney disease reported that $50 to $65 had been stolen from her in May, and she stated that “that lady” (CNA1) stole her money; again, her progress notes over many months did not reflect this allegation. A fourth resident with a history of stroke reported that money had gone missing “a while ago,” believed CNA1 took it, and later stated the money had been taken almost a year earlier; her progress notes similarly contained no documentation of the misappropriation allegation. The Administrator and DON confirmed to surveyors that the facility’s investigation into the reports from these four residents led them to conclude that CNA1 likely stole the residents’ money. The facility’s Abuse Prevention Program Policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of residents’ belongings or money without consent, and stated that each resident has the right to be free from abuse, neglect, and misappropriation, and that the facility would provide a safe environment and protect residents from abuse. The policy also stated that training on abuse prohibition alone does not relieve the facility of responsibility to assure residents are free from abuse and that the facility would provide ongoing oversight and supervision of staff to ensure policies are implemented as written. Despite these policy provisions, multiple residents reported missing money associated with CNA1, and their records lacked documentation of these allegations in the progress notes.
Failure to Follow Dietician-Approved Menus and Provide Ordered Diet Textures and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to follow its planned menus and ensure meals met residents’ nutritional needs and preferences as written and approved. Surveyors reviewed the facility’s week three menus and observed multiple meals where items listed on the menu were not served. For one dinner, the posted menu included minestrone soup, grilled cheese, French fries, lettuce, tomato, onion, apple slices, ketchup, margarine, and 2% milk and/or coffee, but residents actually received minestrone soup, grilled cheese, canned pears, and a choice of 2% milk, coffee, or juice, with no French fries, lettuce, tomato, onion, or apples provided. For a lunch meal, the menu listed chili with beans, baked potato, sweet potato cornbread, red grapes, sour cream and chives, margarine, and 2% milk, coffee, or tea, but residents received chili with beans, baby baked potatoes, sweet potato cornbread or a dinner roll, red grapes, and beverages, with no sour cream and chives served. For a supper meal, the menu listed corn dogs, creamy coleslaw, banana, margarine, and beverages, but residents received corn dogs, tater tots, coleslaw, sugar cookies, and beverages, with no banana served. Staff interviews confirmed that menus were routinely altered without adherence to the written, dietician-approved menu and without appropriate substitutions being reviewed. A cook reported that the facility did not usually order regular baking potatoes because of their size and instead used baby baked potatoes, and that sour cream and chives were usually not included. The Administrator stated that the facility relied on a whiteboard as the working menu and that it was labeled as subject to change. The Dietary Manager stated that menu items varied based on supply and ordering issues and acknowledged being unaware that a registered dietician needed to approve menu adjustments to ensure residents received appropriate amounts and types of food within the same food groups. Residents in a group interview reported they were not provided with the actual facility menu, only what was written on the dry erase board, and that alternates were not posted. They stated they were unaware that French fries and lettuce, tomato, onion, and ketchup were supposed to be part of a prior dinner meal, expressed that they liked French fries and would have wanted them, and noted that pears were served frequently and that no alternate fruit was offered when they did not like pears. The deficiency also included failure to provide an individual resident with meals consistent with her ordered diet texture, care plan, and preferences. One resident with dementia, chronic and acute kidney disease, cellulitis, and a severely impaired BIMS score was care planned as being at risk for significant weight loss and ordered a regular chopped diet with thin liquids, with all foods to be served in bite-sized pieces and requiring setup/cleanup assistance and indirect supervision during meals. Her tray card indicated a soft and bite-sized regular diet with no recorded dislikes. During a lunch observation, the posted whiteboard menu listed chili with beans, baby baked potato, cornbread/dinner roll, and grapes. The resident was served chili, a whole bread roll, and whole grapes; after refusing chili, she was given chicken noodle soup but did not receive any potatoes. She ate the whole roll and whole grapes quickly and independently without staff interaction. In a subsequent interview, the Dietary Manager, DON, and Administrator agreed that the roll should have been cut into bite-sized pieces, the resident should have received bananas instead of grapes, and potatoes should have been served, and confirmed that the facility was expected to provide a diet meeting the resident’s needs and that dislikes or allergies should be documented on the tray card.
Improper Handling of Food Containers and Lids During Meal Service
Penalty
Summary
The deficiency involves failure of dietary staff to prevent contamination of food containers and lids during meal preparation and service for all 78 residents. During a midday observation, a cook was seen taking temperatures of chili with beans, mashed potatoes, and pureed mixed vegetables and, while doing so, repeatedly touched the inside of each food container with her bare hand. In a separate observation, a dietary aide was seen touching the inside of the lids with bare hands while placing the lids on bowls of chili with beans and then placing these bowls on resident trays. When interviewed, the cook acknowledged she was not supposed to touch the inside of food containers with her hand when taking food temperatures, and the dietary aide stated she did not know whether she was supposed to touch the inside of the lids. The dietary manager later confirmed that kitchen staff were not supposed to touch the inside of food containers or lids with bare hands when taking food temperatures or placing lids on bowls of chili. The report states this failure had the potential to increase the risk of foodborne illness for all 78 residents in the facility.
Failure to Consistently Monitor and Document Nutritional Status and Weights
Penalty
Summary
The deficiency involves the facility’s failure to consistently and comprehensively manage nutritional services for a resident identified as being at risk for significant weight loss. The resident was admitted with dementia, chronic and acute kidney disease, and cellulitis of the left lower limb, and had a BIMS score indicating severe cognitive impairment. The admission MDS showed no significant weight loss prior to admission. Physician’s orders directed that the resident receive a regular chopped diet with thin liquids, be weighed weekly on shower days, be offered a bedtime snack each evening, and receive ProStat 30 mL twice daily to support wound healing. The care plan, revised shortly after admission, identified the resident as at risk for significant weight loss and directed that all foods be served as a regular diet cut into bite-sized pieces, that intake be monitored, and that the resident receive diet as ordered. The diet/tray card used by staff showed a soft and bite-sized regular diet and no recorded food or fluid dislikes. Review of the weight record showed weights of 118 lbs, 113.8 lbs, 114.0 lbs, and 110.0 lbs over several days, with no recorded weights after the last entry despite orders for weekly weights. The vitals report showed that meal intake was not documented for 10 of 46 meals since admission, contrary to the care plan and the facility’s Monitoring Nutrient Intake Policy, which required nursing to document percentage of each meal consumed and substitutions. The initial nutritional assessment documented that the resident was underweight and at risk for significant weight loss, with a plan to monitor for need of additional high-calorie supplements based on intake, skin, and weight trends, and for the RD to update the plan of care as needed. There was no documentation of facility follow-up related to the resident’s weight loss since admission, no evidence of efforts to ensure accurate meal intake documentation, and no evidence that weights were obtained as ordered. The DON and Administrator confirmed that no weights were documented after the last recorded date and that meal intake had not been consistently documented, despite the facility’s policies requiring monthly weights or more frequent monitoring as ordered, and recording of all obtained weights in the EMR.
Failure to Remove Staff Following Abuse Allegation
Penalty
Summary
The facility failed to implement protective measures following an allegation of abuse involving a certified nursing assistant (CNA) and a resident. According to the facility's Abuse Prevention Program policy, staff members accused of abuse are to be immediately removed from resident care duties and suspended pending the outcome of an investigation. However, after an incident in which a CNA was alleged to have acted aggressively, spoken in a condescending manner, and physically grabbed a resident's wrist despite the resident's objections, the CNA was allowed to continue working both during the remainder of the shift and on subsequent days while the investigation was ongoing. The resident involved was alert, oriented, and had a history of conditions including gastroenteritis, rheumatoid arthritis, osteoarthritis, weakness, and anxiety disorder. The resident reported feeling that the CNA was abusive, describing the CNA as haughty, condescending, and physically forceful, including grabbing her wrist tightly and yelling in her face. Witnesses, including another CNA and an LPN, corroborated the resident's account, noting the CNA's aggressive behavior, refusal to leave when asked, and the resident's visible distress, including trembling and watering eyes. The LPN observed redness on the resident's wrist and reported the incident to the Director of Nursing promptly. Despite these observations and the facility's policy, the CNA continued to work with residents, including on other shifts and in areas where she could have contact with additional residents. The failure to remove the CNA from resident care duties during the investigation represented a lack of immediate protective action as required by the facility's own procedures, potentially affecting the safety and well-being of other residents.
Resident Subjected to Abusive Behavior by CNA During Care
Penalty
Summary
A deficiency occurred when a resident, who was alert, oriented, and able to communicate her needs, was subjected to abusive behavior by a Certified Nursing Assistant (CNA). The resident reported that the CNA spoke to her in a haughty, condescending, and dictatorial manner, insisted she move her own belongings, and threatened to leave if she did not comply. During care, the CNA grabbed the resident's wrist twice, did not release her grip when asked, and yelled in the resident's face from a close distance. The resident expressed feeling a little afraid during the incident and described the CNA's behavior as escalating. Although no marks were left, the resident stated the grip was tight and confirmed she felt the CNA was abusive. Other staff present corroborated the resident's account. Another CNA described the situation as a "power trip" and confirmed the CNA's condescending tone and refusal to let go of the resident's wrist. A Licensed Practical Nurse (LPN) who entered the room observed the resident visibly trembling and with watery eyes, and noted the CNA was speaking aggressively and inappropriately close to the resident's face. The LPN also observed slight redness near the resident's wrist and reported that the resident calmed after the CNA left. The incident was reported to the Director of Nursing, and statements were gathered for investigation.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the appropriate authorities within the required timeframe. According to the facility's Abuse Prevention Program policy, allegations involving abuse or serious bodily injury must be reported immediately, but not later than two hours after the allegation is made, and all other allegations must be reported within 24 hours. In this incident, a resident with intact cognitive function reported that a CNA spoke to her in a condescending and aggressive manner, grabbed her wrist tightly despite her requests to let go, and refused to leave the room when asked multiple times. The resident described the interaction as abusive and stated she felt afraid during the incident. Multiple staff members, including another CNA and an LPN, witnessed the event and corroborated the resident's account. The LPN observed the resident visibly upset, with watery eyes and trembling, and noted slight redness on the resident's wrist. The LPN also reported that the CNA continued to work the remainder of the shift after the incident. The LPN promptly reported the incident to the Director of Nursing and began gathering witness statements for an investigation. Despite the prompt internal reporting, the facility did not report the incident to the State Survey Agency within the required 24-hour period. The self-report to the state was made three days after the incident occurred, which is not in compliance with the facility's policy or federal regulations. This delay in external reporting constitutes the deficiency identified by the surveyors.
Failure to Report and Document Resident Transfer Accident
Penalty
Summary
A deficiency occurred when a resident with right-sided hemiplegia, impaired mobility, hypertensive intracerebral hemorrhage, chronic pain, and osteoarthritis was being transferred to the bathroom using an EZ stand. During the transfer, the resident's right arm was bumped against the door frame by CNA staff. The incident was not reported to the charge nurse or documented in the medical record as required by the facility's Resident Incident/Accident Reporting Protocol, which mandates immediate reporting and documentation of all incidents and accidents, regardless of severity. The resident later reported severe pain in the right arm to a registered nurse during a medication pass, prompting the facility to gather witness statements from the involved CNAs. Both CNAs confirmed the incident, noting that the resident's arm was hit during the transfer and that the resident declined an ice pack. The Director of Nursing confirmed that the incident was not reported to the nurse on duty, the charge nurse, or the oncoming shift, in violation of facility policy.
Failure to Monitor and Maintain Adequate Hydration for a Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident received adequate fluid intake to maintain acceptable hydration. The resident, who had multiple diagnoses including multiple sclerosis, chronic kidney disease, weakness, and dysphagia, was consistently not meeting the recommended daily fluid intake of greater than 1,400 ml. Despite the facility collecting intake data, staff did not total or assess daily fluid intake, and there was no ongoing assessment for signs and symptoms of dehydration. The resident experienced significant weight loss and was hospitalized twice within a short period for conditions related to dehydration and aspiration pneumonia, both times requiring intravenous fluids. The facility's own policies required assessment and care planning for dehydration risk, including monitoring fluid intake, weighing residents weekly, and updating care plans as needed. However, the facility failed to weigh the resident upon readmission after hospitalization, did not weigh the resident weekly as ordered, and did not update or revise care plan interventions to address the ongoing risk of dehydration and weight loss. There was also a failure to timely communicate significant weight changes to the provider. Interviews with staff revealed confusion about who was responsible for totaling daily fluid intakes, and it was confirmed that no one was consistently performing this task. Documentation showed that the resident's fluid intake was regularly below the recommended amount, and there was no evidence of dehydration assessments being performed. The resident's care plan included approaches to encourage fluid intake and monitor for signs of fluid imbalance, but these interventions were not effectively implemented or updated in response to the resident's declining condition. The lack of daily monitoring and assessment contributed to the resident's repeated hospitalizations and significant weight loss.
Delay in Providing Timely Toileting Assistance
Penalty
Summary
A deficiency occurred when a resident who required extensive assistance for toileting was not provided timely care after requesting to use the bathroom. The resident, who had a history of orthopedic aftercare following surgical amputation, was non-weight bearing on the right leg, and required the use of a Hoyer lift with assistance from two staff members, asked a CNA for help to use the bathroom. The CNA informed the resident that she was on a two-hour toileting schedule and would need to wait, despite the resident not being on such a schedule according to her care plan. The resident waited approximately 1 hour and 20 minutes before being assisted to the bathroom. During this period, staff communication and follow-through were lacking. The CNA who received the request prioritized other residents and did not seek immediate assistance from other staff, even though the Director of Nursing later clarified that staff are expected to respond to such requests as soon as possible. Another CNA, who was supposed to assist, was on break and did not check in with the resident upon returning. The resident was observed participating in an activity during this time, and no staff approached her to ask if she needed to use the bathroom, despite her earlier request. The facility's policy emphasizes person-centered care and the importance of honoring resident preferences and needs, including timely assistance with toileting. The resident expressed discomfort and concern about potentially having an accident due to the delay. Interviews with staff revealed confusion about the resident's toileting schedule and a lack of clear communication regarding her care plan, which contributed to the delay in providing necessary assistance for activities of daily living.
Failure to Notify Physician of Resident's Critical Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician when the resident experienced a significant change in condition. The resident, who had a history of coronary artery disease, diabetes mellitus type 2, chronic heart failure, and other conditions, was admitted to the facility after hospitalization for acute hyperkalemia. On the day of admission, the resident's oxygen saturation fell to 71%, and their pulse dropped below 50, which required immediate notification to the physician according to the facility's policy and the INTERACT change of condition reporting tool. Despite the critical changes in the resident's condition, there was no documentation indicating that the physician was notified. The facility's policy required immediate notification of the physician in such cases, but the staff failed to follow this protocol. The resident's condition was initially addressed by administering oxygen, which temporarily improved their oxygen saturation levels. However, the lack of communication with the physician meant that the resident's overall care and potential treatment adjustments were not adequately managed. Interviews with various staff members, including the MDS nurse, LPNs, and the Regional Clinical Director, revealed inconsistencies in the communication process. The Director of Nursing claimed to have notified the physician via email, but this was not documented in the resident's medical record, and the physician did not respond until two days later. The facility's failure to document and properly communicate the resident's change of condition to the physician resulted in a deficiency in the standard of care provided to the resident.
Inadequate Supervision and Hot Food Management Leads to Resident Burns
Penalty
Summary
The facility failed to provide adequate supervision and assistance during meals, leading to a resident suffering second-degree burns from hot soup. The incident occurred when the resident, who required supervision during meals, was left unsupervised in the dining room. The soup temperature was recorded at 177 degrees Fahrenheit, significantly higher than the facility's policy of serving hot liquids at a maximum of 135 degrees Fahrenheit. This lack of supervision and failure to adhere to temperature guidelines resulted in immediate jeopardy. The resident involved had a history of cerebral infarction, aphasia, weakness, dysphagia, diabetes mellitus type 2, and hemiplegia affecting the right side. The resident's care plan indicated a need for supervision and assistance during meals, including the use of a clothing protector and lidded cups to prevent spills. Despite these documented needs, the resident was not provided with the necessary supervision or protective measures during the meal when the incident occurred. Interviews with staff revealed inconsistencies in the understanding and implementation of supervision requirements. Staff members were unclear about who was responsible for supervising residents in the dining room, and there was a lack of adherence to the facility's policy on serving temperatures. The dietary manager and staff were not adequately educated on the correct serving temperatures, and there was no consistent monitoring of food temperatures at the point of service, contributing to the incident.
Removal Plan
- All residents have been assessed and care plans have been updated to the level of supervision during meals.
- Temperatures have been taken in the kitchen every 15 minutes on the serving steam table tray line due to a need for a part replacement.
- Test trays are done at the point of service for all residents in the dining room and one on each hall tray carts to be checked prior to beginning of service to verify food temp is 135-150 degrees.
- Residents that have a risk of hot liquid injury have cups with lids that snap on and are more difficult to remove and also have staff supervision per their care plan approach as agreed upon by IDT and therapy.
- Dietary staff have had direct supervision at meals and assist taking temperatures of foods prior to service.
- Dietary staff is being educated on the correct temperatures of service of food to be between 135-150 degrees at the point of service to the residents.
- Policies have been changed to reflect this change.
- Nursing staff is being educated on the definition of supervision that is expected in the dining room with the residents that require supervision. This is being audited at every meal to monitor compliance with every meal that residents at risk are having the correct level of supervision that is required to maintain safety with hot liquids/foods.
- Maintenance checked the steam table and parts were ordered and expedited. Replaced prior to the start of service.
- Facility will continue with weekly checks of the steam table for proper function. Due to faulty parts the temps on the food in the steam table were checked every 15 minutes to maintain safe temps.
- QAPI meeting held related to PIP started in relation to the changes that need to be completed.
- Staff education started with temperature changes in the dietary dept.
- Education to nursing staff related to the definition of supervision: 1:1, direct, and direct.
- Care plans related to the level of supervision that is required for residents at risk with hot liquids updated and educated to nursing staff.
- All education is ongoing with this being completed prior to the start of the next working shift.
- Both tray audits and the supervision audits are being completed at all 3 meals 7 days per week to maintain the safe environment for the residents at meal time.
- Resident council meeting held for the update of the residents to the recent changes and the updates to dining service.
- At this time all staff that have worked in the facility have been educated to the changes in policy and the level of supervision that is to be provided in the dining room at all meals.
Inadequate Investigation of Resident Altercation
Penalty
Summary
The facility failed to ensure a thorough investigation of an incident involving potential abuse between two residents. Resident 6, who has severe cognitive impairment and a history of dementia with mood disturbances, was involved in an altercation where they hit Resident 5 on the chest. The incident was witnessed by staff, and immediate actions were taken to separate the residents and provide supervision for Resident 6. However, the facility did not conduct interviews with other residents to determine if there were additional instances of abuse, as required by their Abuse Prevention Program Policy. The facility's policy mandates that all involved persons, including potential witnesses, should be interviewed during an investigation of resident-to-resident altercations. Despite this, the Nursing Home Administrator and Assistant Director of Nursing decided not to interview other residents, considering the incident isolated to Residents 5 and 6. This decision was made after consultation with the facility's regional director, which led to a deficiency in the investigation process as it did not fully comply with the facility's established procedures for handling potential abuse cases.
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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.
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Nursing homes near West Salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeview Health Center | 0.7 mi | ★★★★★ | 2 | 0 |
| Onalaska Care Center | 6.8 mi | ★★★★★ | 1 | 0 |
| Hillview Health Care Ctr | 10.6 mi | ★★★★★ | 15 | 0 |
| Benedictine Manor Of Lacrosse | 11.4 mi | ★★★★★ | 14 | 1 |
| Riverside | 11.7 mi | ★★★★★ | 12 | 0 |
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