Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Oak Park Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident returned after ORIF for a left hip fracture, but the hospital instruction to leave the dressing clean, dry, and intact was not entered into the physician orders. The left hip surgical site was not addressed in the TAR or care plan until later, and nurse progress notes did not document assessment or monitoring of the dressing. Staff and the DON stated the site should have been monitored and documented, and the care plan should have reflected the surgical wound.
A resident with diabetes, venous insufficiency, neutropenia, obesity, and multiple lower-extremity wounds had physician orders for BID wound care to both feet and legs, bilateral tubi grips for edema, and routine Calmoseptine skin treatment. On one morning shift, the MAR showed these ordered treatments were not administered, and there was no documentation of provision or refusal of care. RNs and the DON confirmed that nurses are responsible for wound care and must sign out completed treatments in the EHR, including refusals, but no additional documentation was available for that shift.
A resident with dementia and other psychiatric diagnoses, who is rarely or never understood per MDS, was observed in a wheelchair with a nitroglycerin patch stuck to the wheelchair wheel, despite having no order for nitroglycerin. An RN confirmed the patch was dated from the prior day and stated that only one other resident on the unit had an order for such a patch, which should have been removed the previous night. Both the RN and the DON described the facility’s required process for nitroglycerin patch disposal—folding the patch in half and placing it in a sharps container or immediately removing it in trash—and acknowledged that the patch found on the wheelchair wheel was not disposed of according to facility policy or accepted professional principles.
The facility failed to implement an effective infection prevention and control program during concurrent outbreaks of influenza, RSV, and COVID-19. Several residents with confirmed respiratory infections, including those with severe cognitive impairment and significant comorbidities, had no physician orders for transmission-based precautions and no care plan interventions addressing their infections. Isolation signage was missing from rooms of infected residents, and visitors entered without performing hand hygiene or using PPE. The IP was absent, and the DON and ADON reported they could not access or interpret the EMR infection tracking system, were not systematically tracking infected or non-infected residents’ respiratory symptoms, and had not entered isolation or droplet precaution orders or related care plans for affected residents. Requested outbreak documentation, including line listings, an outbreak management plan, and ongoing symptom tracking, could not be produced, and EMR infection control records showed the outbreak status and contact tracking had not been updated for several days despite multiple residents and staff reporting respiratory symptoms. These failures resulted in an immediate jeopardy finding under F880 for infection control.
The facility failed to designate and employ a qualified IP and had no trained back-up to manage the infection prevention and control program during an active outbreak of COVID-19, influenza, and RSV. The Regional Nurse identified as the IP had a job description focused on overall operations rather than IP duties, and the DON and ADON, who assumed responsibility in the IP’s absence, reported they were not trained as IPs, lacked access to the EMR infection tracking system, and could not interpret infection data. Outbreak documentation, including line listings, an outbreak management plan, and respiratory symptom tracking for non-infected residents, was not available, and electronic infection tracking had not been updated for several days. A resident with a history of stroke, a resident with Parkinson’s disease, and a resident with atrial fibrillation and a recent fracture developed respiratory symptoms and tested positive for influenza, RSV, or COVID-19, while rooms of infected residents lacked isolation/PPE signage, a visitor entered without hand hygiene or PPE, and housekeeping staff were unaware of the infections or required precautions.
Two residents, one cognitively intact with respiratory and cardiac conditions and one severely cognitively impaired with hypertensive heart disease and generalized anxiety disorder, were subjected to verbally abusive statements by an RN. The intact resident reported that when she requested her ordered narcotic pain medication, the RN called her "addicted," and that she witnessed the RN tell another resident to "stop your damn crying" while administering eye drops. The cognitively impaired resident, for whom the facility is home, could not be interviewed. The facility’s investigation documented these reports but the Administrator later stated he did not believe abuse occurred, despite an existing abuse-prevention policy guaranteeing residents freedom from abuse by staff.
A resident was subjected to verbal abuse by a family member, including yelling, swearing, and the throwing of a hanger, as witnessed and reported by others. Despite these reports, facility staff did not interview the resident, implement protective interventions, report the incident, or conduct an investigation, in violation of the facility's abuse prevention policies.
A resident was subjected to verbal abuse by a family member, witnessed by another resident and a visitor, who reported the incident to Social Services. Despite facility policy requiring immediate reporting of suspected abuse, the allegation was not reported to authorities, and no interventions were implemented to protect the resident.
A resident who was cognitively intact was subjected to verbal abuse by a family member, witnessed by another resident and a visitor. The incident was reported to Social Services and the administrator, but the facility did not conduct a thorough investigation, interview the resident, or implement interventions to ensure safety. The event was not reported to authorities as required by policy.
A resident with significant cardiac history and orders to notify the provider for HR >119 had repeated tachycardia and then a pulse of 140 bpm, but the record showed no nursing assessment, repeat pulse check, provider notification, or ongoing monitoring after that reading. The resident was later found pulseless and not breathing, and survey review found no progress notes or nursing assessments documented before death.
A resident with severe cognitive impairment, Parkinsonism, and high fall risk sustained three unwitnessed falls, including two with fractures, and the facility did not document a root cause analysis or investigate toileting-related patterns before relying on generic interventions such as call light reminders, alarms, and bed equipment. In a separate event, a resident with dementia and dysphagia was observed putting crafting pom poms in his mouth during an unsupervised meal while chemicals, lotions, and aerosol cans were left in an unlocked cabinet on the unit.
Food storage and kitchenette sanitation were not maintained according to policy. Surveyors found opened food in a freezer that was not sealed or dated, resident food in a kitchenette refrigerator without a name or date, and microwaves in multiple kitchenettes with dried-on splatters and stains. Surveyors also found that refrigerator and freezer temperature logs for two kitchenettes were inconsistently completed, with many missing entries. The DM, AFSD, ADON, DON, and NHA acknowledged the expected practices and that policies should have been followed.
The facility failed to maintain an effective IPCP. Staff with GI symptoms returned to work too soon, infection surveillance line lists for staff and residents were incomplete and inaccurate, and the facility did not identify common symptom patterns or perform CDC-guided testing after a resident tested positive for COVID. Surveyors also found incomplete outbreak summaries, missed resident cases on surveillance maps, a dirty laundry room, and an RN handling a resident’s catheter bag without EBP PPE or hand hygiene.
Residents’ rooms and shared areas were observed with dirt, debris, dust, hair, urine splatter, dried spills, and brown dried liquid on walls, ceilings, doors, and floors, and staff acknowledged the areas were not clean and that cleaning was inconsistent. A resident with multiple chronic conditions reported her room had not been cleaned adequately, and another resident said housekeeping did not come on weekends. Surveyors also observed one resident’s wheelchair armrest with exposed hard plastic and screws, and another resident’s wheelchair with hardened food buildup throughout the chair.
Inaccurate MDS Assessments for Resident Communication and Fall History: The facility’s MDSs for several residents contained conflicting entries about whether they were understood and could understand others, with section B showing clear speech and comprehension while section C stated they were rarely or never understood. Survey observation and interviews showed residents could communicate more clearly than documented. For one resident, the MDS also conflicted with the record on fall history and injury status, including prior falls with fractures and inconsistent coding of major injury and reentry fall information.
A resident reported dry, tasteless meals and hot foods that were not hot, while another resident said hot foods were often cold and oatmeal was served cold unless staff warmed it. Two cognitively intact residents in room service also reported delayed trays and cold breakfast items. A surveyor test tray from a dining room showed hot items below the facility’s stated hot-holding temperature and cold items above the cold-holding temperature, and the tray was found to be not palatable and not at a safe and appetizing temperature.
Failure to maintain resident dignity and cleanliness: one resident with a suprapubic catheter and severe cognitive impairment was observed in the dining room with the catheter bag uncovered despite stating he wanted it covered when out of his room, and another resident's wheelchair was observed repeatedly dirty with dried food substance on multiple surfaces. Staff acknowledged the uncovered catheter bag and dirty wheelchair were dignity issues and that the wheelchair had not been cleaned.
Failure to investigate and document a resident grievance about being left unattended in the dining room. A resident with COPD, spondylosis with radiculopathy, polyneuropathy, severe cognitive impairment, and dependence for w/c mobility voiced concern that staff repeatedly forgot her after meals and that she was left waiting for help back to her room. An LPN notified the ADON, but no grievance entry, investigation report, corrective action documentation, or resident follow-up was found, and the NHA could not locate evidence that the concern was formally resolved.
Failure to Report Allegations of Abuse: A resident with documented confusion and intact communication abilities made statements that a nurse pinched and jolted her out of bed, and later told her daughter that a staff member had been rough with her during morning care. The NHA acknowledged these could be abuse allegations, stated they were not reported to the State agency, and confirmed the named RN was not removed from resident care after the allegation.
Failure to Thoroughly Investigate Abuse Allegations: A resident with clear speech and comprehension alleged that an RN pinched and jolted her out of bed and later said a staff member was rough with her during morning care. The NHA acknowledged the facility did not complete a thorough abuse investigation, interviewed only the resident, her daughter, and one RN, and did not remove the accused RN from resident care while the allegation was being addressed.
The facility failed to provide written bed-hold notices for residents transferred to the hospital. One resident with COPD and chest pain had no bed-hold documentation after EMS transport, another resident with severe cognitive impairment and an activated POA had no written notice for two hospitalizations, and a third resident with a stroke diagnosis and seizure activity also had no bed-hold notice in the chart. Nursing leadership acknowledged the missing documentation and stated a bed-hold should have been completed for residents transferred out.
A resident with ESRD receiving dialysis three times weekly had no dialysis-specific focus, goals, or interventions in the care plan, despite physician orders to monitor the access site for bleeding and call 911 if bleeding occurred. Staff interviews showed CNAs had not received dialysis-specific training and could not clearly describe what to monitor or how to respond to a bleeding fistula, while the resident reported staff were not checking the access after dialysis appointments. The DON and an LPN stated dialysis care and monitoring should have been included in the care plan.
Medication Error Rate Exceeded Allowed Threshold: Surveyors identified 2 medication errors in 28 opportunities, resulting in a 7.14% error rate. One resident received Lasix outside the ordered administration window, and another resident’s Metoprolol ER tablet was crushed even though it was an extended-release medication and there was no specific order to crush it. The LPN and DON both acknowledged the late administration was a medication error, and the RN stated the resident was on hospice and all medications were being crushed.
Medication Error Involving Crushed Extended-Release Metoprolol: An RN crushed and administered a resident’s Metoprolol Succinate ER 25 mg tablet along with other meds, stating the resident was on hospice and all meds were ordered to be crushed. The resident had HTN and aortic valve disorder, and there was no specific order to crush the ER tablet; the DON later said he would need to check the medication, and the chart banner noted meds were to be crushed.
Expired medication and supplies were found in a first-floor medication room during surveyor observation. A Spikevax single-dose COVID vaccine and 4 urinary catheter insertion tray kits were past expiration, and an RN confirmed the items were expired. The DON stated that medication in storage should not be expired and expired medication should not be given.
A resident voiced concern that bedtime snacks were not being offered, and staff interviews confirmed snacks were not routinely provided to all residents at bedtime. The resident received supper around 5:45 PM and breakfast was not delivered until 8:35 AM the next morning, creating nearly a 15-hour gap without an offered snack. Staff stated snacks were available if asked, but not routinely offered, despite facility policy requiring nourishing snacks when the dinner-to-breakfast interval exceeds 14 hours.
Missing Influenza Immunization Documentation: The facility did not maintain required documentation showing that a resident or the resident’s representative received education on the benefits and potential side effects of influenza and/or pneumococcal immunization, or that the resident received the vaccine, refused it, or had a medical contraindication. A resident signed consent for the 2024/2025 flu vaccine, but the EHR and WI Immunization Registry did not show that the vaccine was actually given; the DON and ADON confirmed the missing documentation.
A resident under Enhanced Barrier Precautions did not receive proper infection control during wound care due to a nurse's failure to secure PPE and perform adequate hand hygiene. The nurse's gown repeatedly fell off, and the resident's foot contacted the nurse's mask and clothing, risking contamination. Interviews revealed gaps in staff training and adherence to infection control protocols.
A resident with intact cognition reported concerns about the cleanliness of her room, which was observed to have dust, debris, and stains on various surfaces, as well as a dark brown spill and spatter that remained unaddressed for several days. The Ancillary Director and facility leadership acknowledged the failure to maintain a clean environment, despite the resident's occasional refusal of chemical cleaners.
The facility failed to create comprehensive care plans for two residents prescribed Melatonin for insomnia, despite lacking a diagnosis of sleep disorders. Both residents received Melatonin daily without proper sleep assessments or evaluations of sleep hygiene. Interviews with staff confirmed the absence of necessary care plans and assessments, leading to the deficiency.
The facility failed to provide consistent and comprehensive wound care assessments for two residents with non-pressure injuries. One resident's wounds were not assessed weekly, and there were discrepancies in wound classification between the facility and external providers. Another resident's new wound was not fully assessed until days later. Technical limitations and inconsistent documentation practices contributed to the deficiency.
The facility failed to provide adequate care and documentation for two residents with pressure injuries. One resident had multiple pressure injuries that were not comprehensively assessed weekly, with inconsistencies in staging between the facility and the Wound Physician. Another resident developed pressure injuries that were misidentified as moisture-associated skin damage, and assessments lacked depth measurements. The facility's failure to follow its policy for weekly assessments and accurate documentation led to inadequate care.
A resident at high risk for falls did not have prescribed safety interventions, such as a low bed and fall mat, in place due to a printing error in the CNA care plan. The CNA was unaware of the resident's fall risk, leading to the absence of necessary precautions until the issue was identified by a surveyor.
Two residents were prescribed antipsychotic medications without appropriate diagnoses or updated consents. One resident received Quetiapine for dementia, and another was given Risperidone for anxiety, both of which are not appropriate indications. Additionally, the consent for an antidepressant was outdated, violating the facility's policy requiring updated consents every 15 months.
Surgical Dressing Not Monitored or Care Planned
Penalty
Summary
The facility did not ensure that a resident who returned after hospitalization for a left hip fracture and ORIF received necessary monitoring and documentation of the surgical dressing and wound site. The hospital discharge instructions stated to leave the dressing on and keep it clean, dry, and intact until the clinic visit, but this instruction was not entered into the resident’s physician orders. The resident’s physician orders and care plan did not address the left hip surgical site until 4/20/26, and the March and early April TARs also did not include the site until that date. The resident’s nurse progress notes did not include an assessment or monitoring of the left hip surgical site. During interviews, RN N, RN O, RN F, and the DON stated that the dressing should have been monitored, the site assessed for signs of infection or other changes, documentation entered into the medical record, and the care plan updated to reflect the surgical site. The survey findings showed that the surgical dressing was not monitored or assessed and the surgical wound was not care planned.
Failure to Provide and Document Ordered Wound and Skin Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered wound care and skin treatments and to document them according to policy for one resident. The facility’s wound care policy requires documentation of the date and time wound care is given, any refusals and reasons, and the signature and title of the person recording the data. The resident was admitted with multiple significant diagnoses, including type 2 diabetes with diabetic polyneuropathy, neutropenia, venous insufficiency, and obesity, and had multiple wounds on both feet and lower extremities. The physician’s orders included Calmoseptine ointment to the buttocks, groin, and folds every morning and at bedtime and after each toileting episode; bilateral high tubi grips on in the morning and off at bedtime for edema; and multiple specific wound care treatments to the left foot toes, left lower extremity, right foot, and right lower extremity, all to be completed twice daily and as needed. On the morning shift of 1/18/26, the Medication Administration Record showed that these ordered treatments were not administered. There was no documentation that the Calmoseptine, tubi grips, or any of the ordered wound care treatments for the resident’s left foot toes, left lower extremity, right foot, or right lower extremity were provided during that shift. Interviews with multiple RNs and the DON confirmed that nurses are responsible for conducting wound treatments and dressing changes and that, when treatments are completed, they are expected to be signed out in the electronic health record, including documentation if a resident refuses treatment. No further documentation was provided to account for the missing wound care treatments on that morning shift.
Improper Disposal of Nitroglycerin Patch Found on Resident’s Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper disposal of a nitroglycerin transdermal patch in accordance with professional standards and facility policy. During observation in the dining area, a surveyor saw a resident seated in a wheelchair with an oval, paper-tape-like object stuck to the wheelchair wheel. On closer inspection, the object was identified as a nitroglycerin patch labeled with a date of 2/3. Review of the resident’s physician orders confirmed that this resident did not have an order for nitroglycerin. The resident’s diagnoses include dementia, major depressive disorder, and schizophrenia, and the most recent MDS indicated that a BIMS could not be completed because the resident was rarely or never understood. When interviewed, an RN stated that only one resident on the unit had an order for a nitroglycerin patch and that the ordered patch would have been removed the previous night. The RN described the facility’s expected disposal process for nitroglycerin patches as folding the patch in half so the medicated sides adhere together and then placing it in a sharps container or wrapping it in gloves, placing it in the resident’s trash, and immediately removing the trash. The RN acknowledged that the patch found on the wheelchair wheel had not been properly disposed of. The DON similarly stated that nitroglycerin patches should be folded on themselves and placed in a sharps container and agreed that the patch observed on the wheelchair wheel was not properly disposed of, indicating noncompliance with the facility’s medication disposal policy and accepted professional principles.
Failure to Implement Effective Infection Control During Concurrent Influenza, RSV, and COVID Outbreaks
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program during concurrent outbreaks of influenza, RSV, and COVID-19, affecting residents, staff, and visitors. The facility did not ensure appropriate physician orders or care plans were in place for multiple residents with confirmed respiratory infections, including influenza, RSV, and COVID. For one resident with a history of stroke and severe cognitive impairment who tested positive for both influenza and RSV, there were no orders addressing management of these infections and no care plan interventions, despite documented respiratory symptoms and positive lab results. This resident’s room lacked any droplet precaution signage, and a visitor entered and exited the room multiple times without performing hand hygiene or using PPE, with staff confirming the absence of signage indicating required precautions. Another resident with Parkinson’s disease and severe cognitive impairment developed respiratory symptoms and later tested positive for influenza. Although a nurse’s note referenced discussion with the NP about Tamiflu and isolation time frames, the comprehensive physician order set contained no orders for transmission-based precautions, and the care plan did not address influenza management. This resident, who had an active order for Tamiflu, also had no droplet precaution signage on the room door. A third resident with dysphagia and a history of sepsis tested positive for influenza, yet had no related physician orders for infection management or TBP and no care plan addressing influenza. A fourth resident, cognitively intact and positive for COVID, had droplet precaution orders in place but no corresponding care plan for COVID management. A fifth resident with vascular dementia and dysphagia tested positive for COVID, but had no droplet precaution orders until several days after symptom onset and no care plan addressing COVID. The facility’s leadership and infection control infrastructure were also deficient. The designated IP was not present in the facility during key survey dates and was unavailable for interview. The DON reported that she and the ADON were responsible for infection control when the IP was absent but stated they could not access or interpret the EMR infection tracking system and had only basic infection control training. The DON acknowledged she was not tracking residents with influenza, RSV, or COVID in an organized manner and was not tracking respiratory symptoms in non-infected residents. She also confirmed that isolation and droplet precaution orders and related care plans had not been entered for residents on droplet precautions for influenza, COVID, and RSV, and that symptom tracking for respiratory illness in all residents had not been occurring prior to a later date. When surveyors repeatedly requested outbreak documentation, including line listings, an outbreak management plan, and evidence of respiratory symptom tracking, the facility could not provide an outbreak management plan or documentation showing systematic tracking of non-infected residents. Infection control documentation from the EMR showed the outbreak status had not been updated for several days, and contact tracking had not been documented beyond its initial entry, despite multiple residents and staff reporting respiratory symptoms during the outbreak. The Administrator and DON were unable to produce an outbreak management plan for the concurrent influenza and COVID outbreaks when interviewed. The DON stated she did not know why droplet precaution signage was missing from the doors of infected residents and reiterated that her expectation was that such signage should be present. A Regional Nurse Consultant confirmed that his expectation for outbreak management included appropriate documentation such as line listings, a functioning outbreak management plan, symptom tracking for staff and residents, and family notification of infection and outbreak status, but the facility lacked this documentation. The combination of missing orders and care plans for infected residents, absent or unclear isolation signage, lack of organized surveillance and tracking, and limited infection control oversight led to the determination of immediate jeopardy related to infection control. The facility’s own policies required prompt identification and management of communicable disease outbreaks, defined thresholds for declaring an outbreak, and assigned responsibilities to the administrator, IP, DON, and staff for surveillance, initiation of transmission-based precautions, and communication with health authorities and families. Policies also required that when residents are placed on transmission-based precautions, appropriate notification be placed on the room entrance door and chart, and that visits to residents on influenza precautions be scheduled and controlled with instruction on hand hygiene and PPE. Despite these written policies, the facility did not implement them during the concurrent outbreaks, as evidenced by the lack of isolation signage, absence of documented TBP orders and care plans for multiple infected residents, and failure to maintain up-to-date outbreak tracking and symptom surveillance. Staff symptom logs provided to surveyors showed multiple employees, including activity aides, housekeepers, CNAs, and an RN, reporting respiratory or flu-like symptoms over several days during the outbreak period. However, there was no evidence that this information was integrated into a broader outbreak management or surveillance system. The EMR infection control management system showed that outbreak status had not been evaluated or updated for several days, and contact tracking documentation had not been continued after its initial entry. These inactions, combined with the absence of a functioning outbreak management plan and the lack of systematic tracking of both infected and non-infected residents, contributed directly to the identified deficiency in the facility’s infection prevention and control program. Overall, the deficiency centers on the facility’s failure to operationalize its infection control policies and CDC-based guidance during simultaneous outbreaks of influenza, RSV, and COVID. This included not ensuring that residents with confirmed infections had appropriate physician orders and individualized care plans, not posting required isolation signage, not maintaining organized surveillance and outbreak tracking, and not having adequately trained and available infection control leadership to manage the situation. These documented failures led surveyors to determine that immediate jeopardy existed under F880 for infection control.
Failure to Designate Qualified Infection Preventionist and Manage Respiratory Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to designate and employ a qualified Infection Preventionist (IP) to develop, implement, and monitor the infection prevention and control program, including during an active outbreak of COVID-19, influenza, and RSV. The facility identified a Regional Nurse as the IP, reportedly working 20 hours per week, but the Regional Nurse’s job description focused on overall facility operations and only generally referenced following established infection control procedures. The facility lacked a qualified back-up IP, and the designated IP was not present in the facility and unavailable for interview during multiple days of the survey while the outbreak was ongoing. During the IP’s absence, the DON and ADON reported they were responsible for managing the infection control program and the current outbreak, but both confirmed they were not trained as IPs, could not interpret the IP’s information, and could not act on her behalf. They also stated they did not have access to the EMR Infection Tracking Program and would not be able to read or understand the information even if they obtained access. The surveyors requested outbreak-related documentation multiple times, including staff and resident line listings, an outbreak management plan, and evidence of respiratory symptom tracking for non-infected residents, but the facility could not provide an outbreak management plan or documentation showing tracking of non-infected residents. Infection control documentation from the facility’s PCC Infection Control Management System showed that outbreak status had not been evaluated, tracked, or updated for several days, and contact tracking documentation had not been updated since the date it was initiated. The deficiency also included specific resident-level findings and infection control lapses. One resident with a history of stroke developed respiratory symptoms and later tested positive for both influenza and RSV, another resident with Parkinson’s disease developed respiratory symptoms and tested positive for influenza, and a third resident with atrial fibrillation and a recent pubic bone fracture developed respiratory symptoms and tested positive for COVID-19. Surveyors observed that required isolation/PPE signage was not posted outside the rooms of residents with RSV and/or influenza. A visitor entered and exited one such resident’s room multiple times without performing hand hygiene or donning PPE, and housekeeping staff reported they were unaware of the residents’ infectious status or required PPE and confirmed there were no signs at the doorways directing them on precautions.
Failure to Protect Residents From Verbal Abuse by RN
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a registered nurse, contrary to its abuse prevention policy that guarantees residents the right to be free from abuse by anyone, including staff. One resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including acute and chronic respiratory failure and heart disease, reported that during the night she requested her ordered narcotic pain medication and the RN responded by referring to her as "addicted." The same resident also reported that on the previous evening she witnessed the RN administering eye drops to another resident and telling that resident to "stop your damn crying" when the resident cried during the procedure. The second resident involved, whose diagnoses included hypertensive heart disease and generalized anxiety disorder and who had a BIMS score of 6 indicating severe cognitive impairment, was described as considering the facility her home and could not be interviewed due to poor cognition. The facility’s own incident reporting and investigation documentation reflected that an investigation into potential verbal abuse of both residents was initiated after the cognitively intact resident reported these events. During a subsequent interview with surveyors, the cognitively intact resident reiterated that she felt verbally abused when called "addicted" and believed the other resident was verbally abused when told to stop her "damn" crying. The Administrator later stated he did not feel either resident was abused and characterized the situation as a "he said/she said" matter, despite the facility’s policy requiring protection from abuse.
Failure to Implement Abuse Prevention Policies Following Family Member's Verbal Abuse
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for one resident. Specifically, after being made aware that a family member verbally abused a resident—including yelling, swearing, and throwing a hanger in the resident's room—the facility did not take steps to protect the resident from further abuse, did not report the incident, and did not conduct an investigation as required by their abuse prevention policy. Witnesses, including another resident and a visitor, reported the incident to Social Services, describing the family member's behavior as abusive and distressing. Despite these reports, the facility did not interview the resident involved, citing the family member's status as activated power of attorney and their instruction that staff could not speak to the resident without their presence. Staff acknowledged the incident could be considered abuse and confirmed that no interventions or plans were put in place to ensure the resident's safety. The facility also failed to report or thoroughly investigate the allegation, contrary to their own policies and federal requirements.
Failure to Timely Report Alleged Abuse by Family Member
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving a resident and a family member was reported to the appropriate authorities within the required timeframe. On the date of the incident, a family member was observed by another resident and a visitor yelling, using profanity, and throwing a hanger in the resident's room. Both witnesses reported the incident to the facility's Social Services staff, who in turn reported it to the previous Nursing Home Administrator. Despite the facility's policies requiring immediate reporting of suspected abuse to local, state, and federal agencies, the allegation was not reported as required. The resident involved was cognitively intact, as indicated by a recent BIMS score. Staff did not interview the resident about the incident due to instructions from the family member, who was the activated power of attorney, that staff could not speak to the resident without her present. No interventions or plans were implemented to ensure the resident's safety or to prevent further abuse, and the facility did not report the allegation to the appropriate agencies as mandated by policy and regulation.
Failure to Investigate and Report Alleged Abuse by Family Member
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported and thoroughly investigated according to state law and facility policy. On 10/22/25, an allegation of verbal abuse by a family member toward a resident was reported to the facility. Witnesses, including another resident and a visitor, described hearing and seeing the family member yelling, using profanity, and throwing a hanger in the resident's room. Both witnesses reported the incident to Social Services, who in turn reported it to the previous Nursing Home Administrator. Despite these reports, the facility did not conduct a thorough investigation, did not interview the resident involved, and did not obtain written witness statements as required by policy. The resident involved was cognitively intact, as indicated by a recent BIMS score of 13. Staff cited the family member's status as activated power of attorney as a reason for not interviewing the resident, stating that the family member required to be present for any staff interaction with the resident. No interventions or plans were implemented to ensure the resident's safety or to prevent further abuse, and the incident was not reported to the appropriate authorities as required by federal and state regulations. The facility's inaction was confirmed by both Social Services and the current Nursing Home Administrator during interviews.
Failure to Assess and Monitor Resident With Severe Tachycardia
Penalty
Summary
The facility failed to provide treatment and care in accordance with orders and professional nursing standards for a resident with a history of cardiomyopathy, prior cardiac arrest with a defibrillator in place, type 2 diabetes mellitus with ketoacidosis without coma, morbid obesity, and major depressive disorder. The resident was cognitively intact with a BIMS score of 15 and had physician orders for CPR and for vital signs every shift, including instructions to update the provider for heart rates greater than 119 or for heart rates over 100 with associated symptoms such as dyspnea, chest pain, dizziness, diaphoresis, or palpitations. The resident’s documented pulse readings showed a pattern of tachycardia over multiple shifts, including values in the 100s and 110s. On the evening shift, the resident’s pulse was documented at 140 bpm. After that reading, there were no further pulse entries on the vitals record and no additional cardiorespiratory assessments documented. The record did not show a nursing assessment, a repeat pulse check, physician notification, or ongoing monitoring after the pulse of 140 was recorded. The resident was later found pulseless and not breathing. A progress note states the resident was found pulseless and non-breathing, CPR was started, and EMS was called. Surveyor review found no progress notes or nursing assessments documented on the day of death or the day before death prior to the resident’s death. Interviews with staff and providers indicated that a pulse of 140 would be considered abnormal and would require assessment, monitoring, and provider notification, but the record did not show that these actions occurred for the resident.
Falls, Unsafe Supervision, and Unsecured Hazards
Penalty
Summary
The facility failed to ensure a resident’s environment remained free from accident hazards and that adequate supervision was provided to prevent accidents. One resident, who had severe cognitive impairment, Parkinsonism, a high fall risk, and dependence for transfers and toileting, sustained three unwitnessed falls. After the first fall, the resident stated she was trying to go to the bathroom and was found on the floor near the bathroom with a bleeding skin tear and chest and rib pain. After the second fall, she was found on the floor next to her bed and later reported head impact; hospital evaluation identified a C1 fracture and left seventh rib fracture. After the third fall, she was found on the floor while attempting to transfer herself to the toilet and was later diagnosed with a closed fracture of the right femur. For each of the resident’s falls, the record review and interviews showed no documented root cause analysis identifying why the falls occurred. The interdisciplinary team notes focused on interventions such as call light reminders, low bed, fall mats, bed placement, and alarms, but the report states there was no evidence that toileting patterns were investigated despite two of the three falls occurring in the early morning and being related to toileting. The report also states there was no evidence of an RN assessment before the resident was moved after the third fall, and that the LPN who found the resident left a message for the ADON rather than obtaining an RN assessment before moving the resident with a Hoyer lift. The facility also failed to provide adequate supervision and environmental safety for another resident with dementia who wandered and rummaged. Surveyors observed crafting pom poms in the resident’s mouth during mealtime while no staff were supervising the dining room, and the resident spit out eight pom poms after being prompted by an RN. Surveyors also observed chemicals, lotions, aerosol cans, and cleaner stored in an unlocked cabinet on the unit, and staff acknowledged that residents on the unit wander and rummage and that such items should be locked up. The resident’s care plan and speech therapy history reflected dysphagia, need for supervision and assistance with meals, and a pureed diet, while staff interviews confirmed the resident had a history of placing nonfood items in his mouth and rummaging through drawers and cabinets.
Food Storage, Microwave Cleanliness, and Temperature Log Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards. During the initial kitchen tour, the surveyor observed an opened bag of turkey sausage links and an opened bag of sliced salami in the walk-in freezer that were not sealed or dated. The Dietary Manager acknowledged that opened bags of food should be sealed and have a use-by date, and facility leadership later stated they would expect policies for food storage and labeling to be followed. In a kitchenette refrigerator on the 100 hall, the surveyor observed a clear sandwich bag containing an opened package of sausage sticks and a snack pack of cheese cubes, nuts, and dried cranberries that did not have a name or date on it. A CNA stated she did not know whose food it was and could not tell how long it had been in the refrigerator because there was no name or date. The Dietary Manager and Assistant Food Services Director indicated that food in the kitchenette refrigerator should be labeled and dated, and facility leadership again stated policies should be followed. The surveyor also observed multiple kitchenette microwaves with dried-on splatters and stains inside, including on the 200 hall skilled side, the 100 hall, and the Memory Care unit. Staff identified housekeeping as responsible for cleaning the microwaves, and one housekeeping aide/CNA began cleaning a microwave while the surveyor was present after being shown its condition. In addition, refrigerator and freezer temperature logs for two kitchenettes were not consistently completed, with multiple missing dates across May, June, July, and August 2025. The Regional Dietetic Manager, Assistant Director of Nursing, Dietary Manager, Assistant Food Services Director, DON, and NHA all acknowledged that the temperatures should have been recorded and that policies should have been followed.
Infection Prevention and Control Program Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program that was designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveyors found that the facility’s infection control line lists for staff and residents were incomplete and inaccurate, daily infection control surveillance was not ensured, and the facility did not recognize commonalities among staff who called in with similar gastrointestinal symptoms in February 2025. The facility also did not rule out a GI or COVID-19 outbreak, and it did not perform testing per CDC guidelines after a resident tested positive for COVID-19 in February 2025. Surveyors reviewed staff line lists for February, April, June, July, and August 2025 and found multiple entries with missing symptom details, missing last-symptom dates, missing return-to-work dates, and return-to-work times that were less than 48 hours after the last nausea, vomiting, or diarrhea symptom. Three staff members returned to work too soon after GI symptoms. One medication administration aide had vomiting and diarrhea, with the last symptom at noon on 2/6/25, but worked on 2/7/25 from 3:00 PM to 6:30 PM. A dietary aide had diarrhea with a last symptom at 11:30 PM on 4/20/25, but worked on 4/21/25 from 5:42 AM to 2:54 PM. A housekeeper had diarrhea with a last symptom on 6/4/25 and worked on 6/5/25 from 5:48 AM to 2:18 PM. The DON stated staff should be off for 48 hours after the last symptom and said it would be a concern if they were coming back the next day. Surveyors also reviewed resident line lists and infection surveillance maps and found that the resident records were incomplete and inaccurate. The February resident log had 26 occurrences, but admission dates were missing, the CAI/HAI column was not completed, only 3 occurrences verified the infection criteria met, and 9 occurrences were missing the resident’s location in the facility. The February COVID line list contained an entry for one resident that did not match the health record, and the DON confirmed that the information on that line matched another resident above it. Surveyors found that six residents with COVID in February and six residents with COVID in April were not tracked on the facility’s surveillance maps as respiratory infections. The facility’s outbreak summaries for February and April did not include a complete overall description of the facility’s response or lessons learned, and staff and leadership acknowledged that the infection control program was being treated as separate pieces rather than one comprehensive program. Additional observations showed the laundry room was dirty, with a thick layer of dust on pipes above the clean laundry folding area, and dust was hanging down where air circulation could blow it toward clean laundry. Surveyors also observed an RN handle a resident’s indwelling catheter bag without gloves, gown, or hand hygiene even though the resident was on Enhanced Barrier Precautions for the catheter. The DON stated it was concerning that the catheter bag was handled without gloves or hand hygiene.
Unclean resident areas and damaged wheelchair equipment
Penalty
Summary
The facility did not ensure residents had a safe, clean, comfortable, and homelike environment, and housekeeping did not maintain sanitary and orderly areas for multiple residents and shared spaces. Surveyors observed several resident rooms with dirt, debris, hair, and dust built up in corners, along baseboards, behind doors, and in windowsills. In multiple rooms, urine was dried around the bottom of toilets and on floors, and food particles and spills were present on the floor. Residents including R33 and R26 voiced concerns about room cleanliness, with R33 stating her room and bathroom had not been adequately cleaned for days. R33, who had diagnoses including major depressive disorder, anxiety, type 2 diabetes mellitus, and acute and chronic respiratory failure with hypoxia, was observed with debris, hair, dirt, dried corn on the bathroom floor, and dried urine on the toilet. On a later observation, the same areas still contained dirt, dust, debris, hair, and urine splatters. Housekeeping staff and the housekeeping manager acknowledged the room was not clean, stated there was no set schedule for deep cleaning, and noted deep cleaning was done only when someone asked or after discharge. R26 stated housekeeping staff did not come on weekends to clean. Surveyors also observed the memory care unit, activity room, dining room, and hallways with brown dried liquid dripping on walls, ceilings, and doors, along with cobwebs, dust, hair, food wrappers, and debris in windowsills, corners, and baseboards. These conditions were still present on repeat observation. Housekeeping staff stated they saw the dried substance and debris and said they could do better, while the housekeeping manager stated the cleanliness did not meet expectations and that spills should be cleaned when they happen. In addition, R47’s wheelchair armrest was observed with the padding and covering peeled away, exposing hard plastic and screws; staff stated the chair had been damaged for several days, that it was the family’s responsibility, and that the chair was not safe or homelike. R37’s wheelchair was also observed with hardened food substance on the arm, seat, braking mechanism, and bars, and staff stated the wheelchair needed to be cleaned.
Inaccurate MDS Assessments for Resident Communication and Fall History
Penalty
Summary
The facility did not ensure Minimum Data Set (MDS) assessments accurately reflected resident status for three sampled residents and one supplemental resident. For R8, R23, and R37, the MDS assessments contained conflicting information between section B and section C. In each case, section B indicated the resident was understood, had clear speech, and could make themselves understood, while section C indicated the resident was rarely or never understood. The report states these sections did not support each other and did not accurately reflect the residents’ cognitive status. R8 was admitted with diagnoses including type 2 diabetes, hypothyroidism, chronic kidney disease, gastro-esophageal reflux disease, and depressive episodes. During survey observation and interview, R8 was able to hold a complete conversation, spoke clearly, and discussed the facility, other residents, and a prior hospital transfer. R8’s MDS with ARD 8/21/25 recorded clear speech, adequate hearing, ability to make herself understood, and understanding of others in section B, but section C stated she was rarely or never understood. R23 was admitted with type 2 diabetes mellitus, congestive heart failure, hyperlipidemia, dementia, and depression. Survey observation showed R23 interacting with staff and residents during lunch, speaking fluent Spanish, and using gestures when needed to communicate. R23’s MDS with ARD 8/6/25 stated in section B that she made herself understood, had clear speech, and understood others, while section C stated she was rarely to never understood. R37, admitted with emphysema, unspecified dementia, anxiety, major depressive disorder, and chronic kidney disease stage 3, had a similar discrepancy on the MDS with ARD 8/8/25, with section B indicating he was understood and made himself understood and section C indicating he was rarely or never understood. For R48, the MDS also contained conflicting and inaccurate information related to communication and falls. R48 had diagnoses including polyneuropathy, COPD, chronic kidney disease, secondary Parkinsonism, chronic pain syndrome, and difficulty walking. Survey observation and interview showed R48 could speak clearly and converse with staff, and the DON stated R48 could articulate and have conversations. However, the MDS with ARD 8/13/25 recorded clear speech, adequate hearing, ability to make herself understood, and understanding of others, while also indicating no falls since entry, reentry, or prior assessment. The record review showed R48 had multiple falls with injury, including a June fall with a C1 fracture and left 7th rib fracture, and an August fall with a right femoral fracture, and the MDS documentation also conflicted regarding whether the June event was a fall with major injury and whether the reentry assessment should have reflected that injury.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not consistently palatable, attractive, or served at a safe and appetizing temperature for residents eating in the facility and in one dining room. During interviews, R82 reported that about 5 times a week the food was dry, tasteless, lacked spices, and hot foods were not hot. R51 also stated that about 5 times a week the hot foods were not hot. R3, whose most recent MDS showed intact cognition with a BIMS score of 15, said the food was terrible, not hot, and that she often had to eat cold eggs in the morning; she also stated that she ate breakfast in her room and usually did not receive her tray until 9:00 AM, although the posted mealtime for her hallway was 7:40 AM. R1, whose most recent MDS showed intact cognition with a BIMS score of 15, stated that she ate in her room and that the food was not always hot, with the majority of the time being cold. She specifically said her oatmeal was cold when delivered and that staff would warm it up if asked, but she had become tired of asking every day. Surveyor testing of a tray from the 200 Skilled Unit dining room found the hamburger at 126.7 degrees Fahrenheit, sweet potato fries at 122.8 degrees Fahrenheit, dill pickle spear at 115 degrees Fahrenheit, milk at 38.9 degrees Fahrenheit, and water at 42.9 degrees Fahrenheit. The surveyor tasted the tray and found the hamburger and fries were not as hot as they should have been, the pickle was warm when it should have been cold, and the tray was not palatable and not at a safe and appetizing temperature. Dietary leadership and facility administration acknowledged that hot foods should be above 135 degrees Fahrenheit and cold foods below 41 degrees Fahrenheit, and stated they would expect food preparation and service policies to be followed.
Failure to Maintain Resident Dignity and Cleanliness
Penalty
Summary
The facility did not ensure that residents were maintained in a dignified manner and supported in self-determination for 2 of 17 sampled residents. One resident with a suprapubic catheter related to neuromuscular dysfunction of the bladder had a care plan intervention directing that the catheter bag and tubing be positioned below the bladder and away from the room entrance or covered for privacy. The resident had a BIMS score of 6 out of 15, indicating severe cognitive impairment, and stated that while the catheter bag did not bother him in his room, he wanted it covered when he was out of his room. Surveyors observed this resident eating lunch in the dining room with the catheter bag uncovered, and later observed the same condition again while he was eating breakfast in the dining room. When interviewed, the resident stated that the catheter bag should be covered and that he liked it covered when he was out of his room. An RN stated that catheter bag covers were available and that she would get one, and also stated that an uncovered catheter bag would be a dignity issue. A CNA stated that some residents have catheter bag covers and agreed that the resident might feel bad if he wanted it covered and it was not. A second resident was observed sitting in a wheelchair that had dried brown, yellow, red, and orange food substance on the arm, braking mechanism, side, and seat of the chair. Surveyors and staff later observed the same wheelchair still dirty, with hardened food substance that appeared to have accumulated from more than one meal. An RN stated the wheelchair was not clean and that night shift CNAs were to clean residents' wheelchairs. A housekeeper stated that cleaning spills was nursing's responsibility, that the wheelchair was not clean, and that it should be cleaned regularly but had not been.
Failure to Investigate and Document Resident Grievance About Being Left Unattended
Penalty
Summary
The facility failed to document a thorough investigation and did not resolve a grievance as outlined in its grievance policy for one resident who voiced concern about being left unattended in the dining room after meals. The policy stated that grievances and complaints would be investigated, documented on the grievance log, and reported with findings and corrective action, but the record review did not show a grievance entry, investigation report, recommendations for corrective action, or documented follow-up with the resident. The resident involved had diagnoses including COPD, spondylosis with radiculopathy, and polyneuropathy, and the most recent MDS showed a BIMS score of 6, indicating severe cognitive impairment. Functional assessment data showed the resident was dependent in wheelchair use and required assistance of one staff member for mobility/locomotion. During a Resident Council meeting, the resident and two other residents reported that the resident was often left in the dining room after trays were removed and was not helped back to her room, usually after lunch and supper. The resident stated she had fallen asleep while waiting for assistance and that the situation made her feel embarrassed. An LPN documented that she found the resident crying in the dining room and that the resident said staff always forgot her every day and wanted to know why it kept happening. The LPN noted she would notify the DON and later documented that the resident wanted to report it because she was tired of it happening. The LPN told surveyors she texted the ADON about the concern, but the grievance was not found in the July or August grievance log. The ADON stated she believed the DON handled it but could not confirm a grievance was completed, and the NHA stated she did not recall being informed and could not locate any grievance form, investigation, corrective action recommendations, or documentation that anyone followed up with the resident regarding a resolution.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility did not ensure that allegations involving possible abuse were reported immediately to the administrator, the State agency, and other officials in accordance with facility policy and federal regulations. The cited policy required all reports of resident abuse, neglect, exploitation, or misappropriation of resident property to be reported to local, state, and federal agencies as required, with immediate reporting defined as within 2 hours for allegations involving abuse or serious bodily injury, or within 24 hours for allegations that do not involve abuse or serious bodily injury. R48, who was admitted to the facility and whose most recent MDS indicated intact hearing, clear speech, and the ability to understand others, made statements on 8/9/25 that a nurse had pinched her and jolted her out of bed. In the same note, the resident was described as tearful, confused, and asking where her daughter and grandkids were, while also stating that the nurse had done this to her. Later that day, the resident’s daughter reported that the resident said a staff member named [name] had gotten her up that morning and had been rough with her. The nurse documented that the resident continued to insist that [name] was rough with her, even after being reminded that there was no [name] on staff. During interview, the NHA acknowledged that these statements could represent two allegations of abuse, even though the resident was confused. The NHA stated the allegations were not reported to the State agency. The NHA also stated that the RN who was named in the allegation was not removed from resident care after the allegation was made, and that the facility should have followed its abuse policy to protect the resident, support the resident, and determine whether abuse occurred.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility did not ensure that allegations of abuse were thoroughly investigated or that the resident was protected pending investigation for one resident. R48’s record showed that she had adequate hearing, clear speech, and clear comprehension on her most recent MDS, yet on 8/9/25 she was documented as tearful and asked her nurse, "Why would you pinch me and jolt me out of bed?" The nurse documented that this was the first interaction of the day and that R48 continued to ask where her daughter and grandkids were and whether they were okay. Later that same day, R48’s daughter reported that the resident said a staff member had been rough with her during morning care. The nurse documented that the resident continued to insist that a named staff member had been rough with her, even after being reminded that there was no staff member by that name. The nurse also documented that a nursing student witnessed the morning get-up and observed staff being appropriate and gentle with care, but the daughter remained unsatisfied with the explanation. During interview, the NHA stated the facility’s expectation was to report allegations of abuse immediately and acknowledged that the allegations could be two separate abuse concerns. The NHA stated she did not conduct a thorough investigation to rule out abuse and only interviewed R48, her daughter, and one RN, without interviewing other staff, students, or residents. The NHA also stated the RN accused in the allegation was not removed from resident care after the allegation was made.
Missing Bed-Hold Notices for Hospital Transfers
Penalty
Summary
The facility did not provide the required written bed-hold documentation for residents who were transferred to the hospital. The facility policy stated that residents and/or representatives are to be informed in writing of the facility and state bed-hold policies, including notice well in advance of transfer and again at the time of transfer or within 24 hours if the transfer is an emergency. Survey review found that this documentation was missing for multiple residents who left the facility for hospital care. For one resident with diagnoses including COPD and lumbosacral spondylosis with radiculopathy, progress notes documented that the resident reported shortness of breath and chest pain, 911 was called, and the resident was transported to the hospital. Survey review of the electronic record found no evidence that a bed-hold notice was provided to the resident or representative for that transfer. The NHA stated the facility used blue transfer packets that included bed-hold information and that a bed-hold should have been completed for this transfer. For another resident with diagnoses including Bell’s palsy, cardiomegaly, gastrostomy malfunction, spinal stenosis, glaucoma, aphasia, anxiety disorder, mild cognitive impairment, and anemia, the MDS showed a BIMS score of 00 and the resident had an activated POA. The resident was transferred to the hospital twice for changes in condition, but survey review found no written bed-hold notice in the record for either hospitalization. The facility later provided one bed-hold and storage agreement signed by the representative after the resident had already returned to the facility. For a third resident with a diagnosis of cerebral infarction due to occlusion or stenosis of a small artery, progress notes documented seizure activity followed by EMS transport to the hospital. Interviews with nursing leadership confirmed there was no bed-hold notice in the chart for that transfer, and staff stated there should have been one for any resident transferred out.
Dialysis Care and Emergency Response Not Addressed in Care Plan
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for a resident with end stage renal disease who received dialysis three times per week at an outside certified dialysis center. The resident was cognitively intact with a BIMS score of 15 out of 15. Although the resident’s physician orders included dialysis Monday, Wednesday, and Friday and monitoring of the hemodialysis access site for bleeding with instructions to apply pressure and call 911 if bleeding was noted, the resident’s care plan did not include a dialysis focus, goal, or interventions related to dialysis services, vascular access assessment, monitoring for complications, or emergency steps for staff to take if the resident bled from the dialysis fistula. Record review and interviews showed that facility staff were not consistently monitoring the resident’s dialysis access or were unable to describe what should be monitored. The resident stated she was not sure how often staff checked her access port for bleeding or infection and believed staff were not checking it after every dialysis appointment. The facility policy required routine checks for infection, patency, and circulation in the access arm, as well as immediate action for major post-dialysis bleeding. However, the care plan did not reflect these requirements, and the facility did not ensure ongoing assessment before and after dialysis treatments received at the dialysis facility. Interviews also showed that CNAs and an LPN were not fluent in the emergency response for a bleeding dialysis fistula. CNAs stated they had not received dialysis-specific training and described only general actions such as calling or getting the nurse. One CNA said she would call the nurse if she saw bleeding, another said she would run to get the nurse or use the call light, and another said she would tell the nurse. The DON stated it was his expectation that staff know how to care for and monitor dialysis residents and know what to do in a dialysis emergency, and the LPN stated dialysis care should be on the resident’s care plan.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility did not ensure that medication error rates remained below 5 percent. During a medication pass task, surveyors identified 2 errors in 28 opportunities, resulting in a 7.14% error rate and affecting 2 of 6 residents observed. The facility policy stated that medications are to be administered in accordance with prescriber orders and within one hour of the prescribed time unless otherwise specified. One error involved R53, who had diagnoses including chronic atrial fibrillation. R53’s physician order for Lasix (furosemide) 10 mg by mouth daily for edema was scheduled for 7:00 AM on the MAR. Surveyors observed the medication administered at 8:40 AM and documented at 8:41 AM. During interview, the LPN stated medications should be given within an hour before or after the scheduled time and acknowledged that giving the 7:00 AM medication at 8:40 AM would be a late medication error. The DON also stated that the 8:40 AM administration of a 7:00 AM medication would be considered a late medication. The second error involved R16, who had diagnoses including essential hypertension and a nonrheumatic aortic valve disorder. R16 had an order for Metoprolol Succinate ER 25 mg, 1 tablet by mouth for hypertension, with instructions to hold if pulse was below 50. Surveyors observed an RN crush the extended-release tablet along with other medications and administer them with applesauce. The RN stated there was an order for all of R16’s medications to be crushed because the resident was on hospice, but there was no specific order to crush the Metoprolol Succinate ER tablet. The DON reviewed the medication and the MAR, and the record showed the Metoprolol Succinate ER was later discontinued and replaced with Metoprolol Tartrate.
Medication Error Involving Crushed Extended-Release Metoprolol
Penalty
Summary
A significant medication error occurred for one resident who was admitted with diagnoses including essential hypertension and a nonrheumatic aortic valve disorder. The resident had a physician order for Metoprolol Succinate ER 25 mg, to be given as one tablet by mouth for hypertension and held if pulse was below 50. During medication administration, an RN prepared to crush eight medications for the resident, including the Metoprolol Succinate ER tablet, and administered them with applesauce after stating there was an order for all of the resident’s medications to be crushed because the resident was on hospice. The surveyor interrupted the administration and asked whether an extended-release medication should be crushed. The RN continued to crush and give the medication, and the DON later stated he would need to look at the medication to determine whether it could be crushed. The surveyor observed that the Metoprolol Succinate ER tablet was solid, and the resident’s chart banner indicated medications were to be crushed, but there was no specific order to crush the Metoprolol Succinate ER tablet. The facility’s policy defined a medication error to include failure to follow manufacturer instructions or accepted professional standards, including crushing a medication on the do-not-crush list without an order.
Expired medications and supplies found in medication room
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional standards in 1 of 2 medication rooms reviewed. During observation of the first-floor medication room with RN P, the surveyor found a Spikevax single-dose COVID vaccine in the refrigerator with an expired date and 4 urinary catheter insertion tray kits in a cupboard with expired dates. The surveyor asked RN P to read the expiration dates, and RN P confirmed that all of the items were expired and removed them. The facility policy on medication labeling and storage states that discontinued, outdated, or deteriorated medications or biologicals are to be handled through the dispensing pharmacy for return or destruction. The DON stated that medication in storage should not be expired and expired medication should not be given.
Bedtime Snacks Not Routinely Offered When Meal Gap Exceeded 14 Hours
Penalty
Summary
The facility did not ensure that snacks were offered at bedtime when there was more than a 14-hour span between the evening meal and breakfast for one resident. The resident voiced concerns that snacks were not being offered at bedtime. The facility policy stated that evening snacks would be offered routinely to all residents and that nourishing snacks would be offered if the time between the evening meal and the next day's breakfast exceeded 14 hours. Survey observations and interviews showed that the resident received supper around 5:45 PM and breakfast was delivered the next morning at 8:35 AM, creating nearly a 15-hour gap without a snack being offered. The resident stated breakfast was often late and that a nighttime snack was not offered, only available if requested and limited to items such as Jello, pudding, or saltine crackers. Staff interviews confirmed that snacks were not routinely offered to all residents at bedtime, but were available if residents asked, and the AFSD stated that residents should be offered a nutritious snack when the time between dinner and breakfast exceeded 14 hours.
Missing Influenza Immunization Documentation
Penalty
Summary
The facility did not ensure that the resident’s medical record included documentation showing that the resident or the resident’s representative was provided education about the benefits and potential side effects of influenza and/or pneumococcal immunization, and did not ensure documentation showing that the resident either received the influenza and/or pneumococcal immunization or did not receive it because of medical contraindication or refusal. This deficiency affected 1 of 5 residents reviewed for immunizations, identified as R33. R33 had documentation showing an influenza vaccine was administered on 2/9/24. R33 also signed a vaccine consent and administration record form on 10/21/24 indicating she received education about the influenza vaccine and wanted to receive it for the 2024/2025 season. However, R33 did not have an influenza vaccine listed in the EHR for the 2024/2025 influenza season. During interviews on 8/26/25, the ADON stated R33 should have received the influenza vaccine and would look for documentation, and the DON later stated he could not find documentation that R33 received the 2024/2025 influenza vaccine and confirmed it was not listed in the Wisconsin Immunization Registry.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) and inadequate hand hygiene practices by a Registered Nurse (RN) during the treatment of a resident. The resident, who was under Enhanced Barrier Precautions due to conditions including Type 2 Diabetes Mellitus with Diabetic Neuropathy and Peripheral Vascular Disease, required specific infection control measures during wound care. However, the RN did not secure the gown properly, leaving it open in the back, and repeatedly allowed it to fall off the shoulders during the procedure, compromising the protective barrier. Throughout the treatment, the RN failed to maintain proper hand hygiene, performing handwashing for significantly less than the recommended 20 seconds. The RN's gown frequently fell off, and at one point, the resident's foot with an old dressing touched the RN's N95 mask, stethoscope, and clothing, leading to potential contamination. Despite these issues, the RN continued the procedure without addressing the gown's fit or the contamination risk. Interviews with the RN and the Director of Nursing (DON) revealed a lack of awareness and adherence to proper infection control protocols. The RN admitted the gown did not fit properly and had not reported this issue to the DON. Additionally, there was a discrepancy in the understanding of the required duration for hand hygiene, with the RN and DON providing incorrect information. These lapses in infection control practices highlight deficiencies in staff training and adherence to established policies, potentially compromising resident safety.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, identified as R31, as evidenced by multiple observations of unclean conditions in her room. R31, who has intact cognition with a BIMS score of 15 out of 15, expressed concerns about the cleanliness of her room. Observations by the surveyor on multiple occasions revealed dust-coated window blinds, debris and stains on window sills, dust on shelving, dried liquid stains on the bedside table, and debris on the floor. Additionally, a dark brown spill and spatter were noted under the bed and on the wall behind the bed, as well as near the door and the dirty linen collection bin. The Ancillary Director acknowledged that the room should have been cleaned more frequently and that the dark brown spill/spatter should have been addressed immediately. It was noted that R31 sometimes refused the use of chemical cleaners, but alternative cleaning methods such as using a dust cloth or soap and water were not employed. The Nursing Home Administrator and Director of Nursing also confirmed that the room should not have remained in such a state for six days and that housekeeping should have been maintaining cleanliness regularly.
Failure to Develop Comprehensive Care Plans for Residents on Melatonin
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents who were prescribed Melatonin for insomnia, despite neither having a diagnosis of insomnia or any other sleep disturbance disorders. Resident 9, with diagnoses including cerebral infarction, unspecified dementia, anxiety disorder, and major depressive disorder, was receiving Melatonin daily without a documented sleep assessment or evaluation of sleep hygiene. Similarly, Resident 42, diagnosed with Alzheimer's disease and dementia, was also receiving Melatonin daily without an up-to-date sleep assessment or evaluation of sleep hygiene. The facility's care plans for both residents lacked documentation regarding the use of Melatonin for insomnia and did not include monitoring of sleep hygiene or the medication's effectiveness. Interviews with facility staff, including the Registered Nurse Unit Manager and the Director of Nursing, revealed an acknowledgment of the deficiency. Both staff members indicated that the residents should have had care plans related to sleep, including monitoring of sleep hygiene and the effectiveness of Melatonin. Additionally, they acknowledged that sleep assessments should be conducted quarterly or at least annually, but these assessments were not completed for the residents in question. The lack of a comprehensive care plan and failure to conduct necessary assessments led to the deficiency identified by the surveyors.
Inconsistent Wound Care Documentation and Assessment
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services consistent with professional standards of practice, specifically for two residents with non-pressure injuries. One resident, with a history of multiple medical conditions including peripheral vascular disease and chronic osteomyelitis, had several non-pressure injuries that were not comprehensively assessed weekly. The documentation for the location and etiology of these injuries was inconsistent between the facility and the Wound Physician. The facility's records often lacked depth measurements, and there were periods where no weekly assessments were documented. Additionally, there was confusion regarding the classification of wounds as pressure or non-pressure, leading to conflicting documentation between the facility and external wound care providers. Another resident developed a non-pressure injury that was not comprehensively assessed until several days after its initial documentation. The resident, who had a history of diabetes and other significant health issues, was noted to have a new blister and an open area near the rectum, which was not fully assessed until seen by the Wound Physician. The facility's process for wound assessment was hindered by technical limitations, such as a camera system that did not measure wound depth, and there was a lack of manual documentation to compensate for these limitations. The facility's failure to conduct comprehensive and consistent wound assessments, along with discrepancies in wound classification and documentation, contributed to the deficiency. The nursing staff, including a registered nurse who was not wound care certified, did not consistently review or align their documentation with that of the Wound Physician or the wound clinic, leading to ongoing issues in the management and treatment of the residents' wounds.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for two residents with pressure injuries. One resident, identified as R7, had multiple pressure injuries, including a Stage 4 pressure injury to the left heel, a Stage 4 pressure injury to the left lateral foot, and a Stage 3 pressure injury to the left first toe. The facility did not comprehensively assess these wounds weekly, and there were inconsistencies in the documentation of the staging of the pressure injuries between the facility and the Wound Physician. The facility's documentation often lacked depth measurements, and the staging was not accurate according to the Wound Physician's assessments. Another resident, identified as R12, developed a Stage 2 pressure injury to the sacrum, which was not comprehensively assessed until a week later when seen by the Wound Physician. The facility's documentation incorrectly identified the wound as moisture-associated skin damage (MASD) rather than a pressure injury, as documented by the Wound Physician. Additionally, R12 developed a Stage 2 pressure injury to the right thigh, which was also not comprehensively assessed until several days later. The facility's documentation continued to misidentify the etiology of the wounds, and there were no depth measurements recorded. The facility's failure to accurately assess and document the pressure injuries led to a lack of consistent and appropriate care for the residents. The facility's policy required weekly assessments of pressure injuries, but this was not consistently followed. The use of a camera for wound assessments was cited as a reason for missing depth measurements, but manual measurements were not taken when the camera was not functioning. The discrepancies between the facility's documentation and the Wound Physician's assessments contributed to the deficiency in care provided to the residents.
Failure to Implement Fall Risk Interventions for a Resident
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures to prevent accidents for a resident identified as R5, who was at high risk for falls. R5 had a history of transient cerebral ischemic attack, essential tremor, and dementia with severe cognitive impairment. The care plan for R5 included interventions such as a low bed and a fall mat to mitigate the risk of falls. However, during an observation, it was noted that these interventions were not in place while R5 was in bed. The bed was not in the lowest position, and the fall mat was not next to the bed, contrary to the care plan requirements. The deficiency was further highlighted when a CNA, responsible for R5's care, was unaware of the fall risk interventions due to a printing error in the CNA care plan sheets. The CNA care plan did not list R5 as a fall risk, leading to the absence of necessary safety measures. Upon inquiry, the CNA found the fall mat in R5's bathroom and placed it next to the bed, and subsequently lowered the bed to the correct position. The RN and RNUM confirmed the oversight, attributing it to a printing error that omitted the fall interventions from the CNA care plan sheets for that day.
Inappropriate Use of Psychotropic Medications and Lack of Consent
Penalty
Summary
The facility failed to ensure that residents using psychotropic drugs had appropriate assessments, diagnoses, and consent, affecting two residents. One resident, identified as R9, was prescribed Quetiapine Fumarate, an antipsychotic, for dementia, which is not an appropriate indication for such medication. This resident was admitted with diagnoses including cerebral infarction, unspecified dementia, anxiety disorder, and major depressive disorder. The facility's policy on psychotropic medication use requires that medications be clinically indicated to treat a specific condition, which was not adhered to in this case. Another resident, R42, was prescribed Risperidone, an antipsychotic, for anxiety, and Citalopram, an antidepressant, without active consent. R42 was admitted with Alzheimer's disease, dementia, and anxiety disorder, but did not have a diagnosis of insomnia or sleep disturbance disorders. The consent for Citalopram was outdated, having been signed over 15 months ago, and the facility's policy requires consents to be updated every 15 months. Interviews with the Registered Nurse Unit Manager and the Director of Nursing confirmed the lack of appropriate diagnosis and consent for the antipsychotic medications prescribed to these residents.
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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 Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Health And Rehabilitation Center | 1.7 mi | — | 39 | 0 |
| Oakwood Village East Health And Rehab Center | 4.9 mi | ★★★★★ | 2 | 1 |
| Capitol Lakes Health Center | 5.4 mi | ★★★★★ | 11 | 1 |
| Avina Of Sun Prairie | 6.7 mi | ★★★★★ | 10 | 0 |
| Sun Prairie Senior Living | 7.4 mi | ★★★★★ | 23 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.