Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Park Place Of Janesville during CMS and state inspections, most recent first.
The facility failed to follow its grievance policy and document investigation and resolution efforts after a resident’s AHCPOA emailed the NHA with multiple care concerns, including dirty clothing, poor hygiene, an untreated red eye needing more frequent drops, lack of snacks and fluids despite the resident calling out for something to drink, and missing eyeglasses and hearing aids. Although facility policy requires grievances to be documented on forms, routed to the grievance official, logged, investigated, and concluded with a written decision, no grievance entry or related documentation was found. The NHA reported treating these repeated concerns as routine day-to-day care issues rather than formal grievances and acknowledged not completing the required grievance documentation or investigation.
Surveyors observed staff entering kitchen and kitchenette areas without required hairnets during food preparation and service, and found multiple food safety violations including unlabeled, expired, and uncovered food items, a dented can in circulation, and incomplete temperature monitoring of refrigeration units. There was also confusion among staff regarding responsibility for cleaning and monitoring food storage areas, with no clear policy in place.
Surveyors found that multiple residents were routinely served meals using plastic silverware and Styrofoam cups, both in their rooms and in the dining room, despite available supplies of regular dishware. Several cognitively intact residents expressed difficulty and dissatisfaction with the use of disposables, and staff interviews revealed inconsistent practices and a lack of clear procedures for ensuring adequate regular utensils and cups were provided, resulting in a failure to uphold residents' dignity during meals.
Several residents were found living in unclean and uncomfortable rooms, with unmade beds, overflowing trash, debris, and soiled items left unattended. Staff and residents confirmed the lack of regular cleaning, and housekeeping staff reported no consistent cleaning schedule or documentation. These conditions persisted despite facility policy requiring regular cleaning and immediate attention to visibly soiled areas.
A resident with paraplegia, anxiety disorder, PTSD, and depression, who was cognitively intact and his own decision maker, did not have a documented discharge care plan or care conference. The facility's policy requires resident participation in care planning, but interviews and record review confirmed that discharge planning was not discussed or documented for this resident.
Two residents with indwelling catheters did not receive appropriate care: one had a catheter placed without a documented diagnosis or care plan, and another's catheter bag was left uncovered and visible from the hallway, contrary to the care plan. The DON and CNA confirmed these lapses in catheter management and privacy.
A resident with PTSD did not receive a complete trauma assessment or have a care plan addressing their trauma history, triggers, or interventions. The social worker confirmed that the assessment was incomplete and the care plan did not address the resident's PTSD, resulting in a failure to provide trauma-informed, culturally competent care.
Surveyors found an open multi-dose Tuberculin vial in the medication room refrigerator that lacked both an open date and expiration date, in violation of facility policy. An RN confirmed the vial should have been dated and that all staff share responsibility for labeling. The DON was unaware of the issue and mistakenly believed the vials were single-use, but the pharmacy confirmed they were multi-dose.
A resident with multiple diagnoses, including heart failure, was admitted while already receiving hospice services, but the facility failed to maintain required hospice documentation and did not have a coordinated hospice care plan in the EHR. Staff interviews revealed inconsistent processes for obtaining and storing hospice records, and hospice documentation was only provided after surveyor intervention.
Staff failed to follow infection control protocols for two residents requiring transmission-based precautions. An LPN entered the room of a COVID-19 positive resident without any PPE, despite clear signage and policy requirements. In a separate incident, a nurse performed tracheostomy care for another resident without wearing a gown and did not perform hand hygiene between glove changes, contrary to enhanced barrier precautions and facility policy. Leadership confirmed that proper PPE and hand hygiene were required in both cases.
The facility did not conduct thorough investigations into multiple allegations of abuse, neglect, and mistreatment, including a case of injury of unknown origin, reports of rough care and neglect, and a verbal altercation involving a family member. Investigations lacked key documentation such as staff and resident interviews, skin assessments, and evidence of staff education, with facility leadership acknowledging incomplete records and missing documentation.
A facility failed to monitor a resident's diuretic medication and provide necessary supplements, resulting in hospitalization due to critically low blood levels. Additionally, the facility did not consistently document weights for two residents as ordered by physicians, increasing health risks. Staff interviews revealed issues with processing orders and documentation, contributing to these deficiencies.
The facility failed to provide sufficient nurse staffing, leading to delayed response times to call lights and unmet resident needs. Despite the facility's assessment indicating specific staffing requirements, the schedule showed significant gaps, with missing RNs or LPNs and CNAs not showing up for work. Residents and family members reported long waits for assistance, and staff acknowledged being overwhelmed with tasks, indicating inadequate staffing to meet resident needs.
A facility failed to document and communicate necessary information during a resident's hospital transfer. The resident, with T-cell lymphoma and other conditions, was transferred due to worsening health. The transfer form lacked critical details about the resident's condition and necessary documents, which was acknowledged by the Regional Clinical Nurse.
A facility failed to provide ADLs according to the care plan for a resident with adult failure to thrive, resulting in an unkempt appearance and lack of documented showers. Staff interviews revealed confusion about shower schedules and inadequate documentation of care refusals, while the ADON confirmed the resident's appearance and the need for family involvement in providing clothing.
A resident with multiple wounds, including a stage 3 pressure ulcer and a scalp burn, was not consistently assessed or monitored by the facility. The resident refused wound care multiple times, but the provider was not notified as required by the facility's policy. Additionally, there was a discrepancy in the wound care provided, with Medi-honey being used instead of the prescribed Silvadene. The Regional Clinical Nurse confirmed that the assessment and monitoring of the wounds were not conducted, leading to a deficiency in care.
A resident with Parkinson's disease and dementia did not receive his Trazadone medication at the preferred time, as specified in his physician's orders. The medication was administered late on two occasions, once by an agency nurse unfamiliar with the resident's needs. The Regional Clinical Nurse confirmed the timing error, and the resident's family member reported the issue to the Regional Nurse.
The facility failed to maintain complete and accurate medical records for two residents, leading to potential unmet care needs. One resident with T-cell Lymphoma and skin issues had undocumented skin/wound assessments over several days, while another resident with colon cancer and pressure ulcers had incomplete daily charting. The ADON acknowledged the documentation lapses, which should have been recorded daily.
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, affecting all 12 residents. Staff did not follow policies on hair restraints, dishwashing, thermometer sanitization, hand washing, and food labeling. Chef Q and other staff were observed not practicing proper hand hygiene and glove use, and undated food items were found in multiple locations. Residents R2 and R4 were directly affected by these deficiencies.
The facility failed to ensure accurate PBJ reporting, resulting in deficiencies for not maintaining 24-hour licensed nursing coverage and RN hours on multiple dates across two fiscal year quarters. The NHA provided documentation to prove compliance, but the CASPER Report did not reflect this.
The facility failed to maintain an effective infection prevention and control program, allowing staff to return to work too soon after reporting symptoms and not documenting symptom onset accurately. Additionally, a CNA performed catheter care on a resident without appropriate hand hygiene, handling clean and dirty items interchangeably.
The facility failed to ensure that five residents received necessary services for good nutrition, grooming, personal, and oral hygiene. Residents did not receive scheduled showers, and one resident was left without food and utensils during mealtime. This was contrary to the facility's policy and care plans.
The facility failed to provide an ongoing program of activities designed to meet the interests and well-being of residents. Care plans were not person-centered, and activity programming was inadequate, affecting seven residents. Staff acknowledged the need for individualized care plans but failed to implement them effectively.
The facility failed to ensure residents were treated with dignity and respect, affecting three residents in the dining area. One resident waited 29 minutes for assistance with his meal while having an uncovered catheter bag, uncombed hair, and an unshaven face. Another resident's catheter bag was uncovered despite her preference for it to be covered. A third resident with moderate cognitive impairment also had an uncovered catheter bag. Staff acknowledged the need for dignity bags but did not consistently use them.
A resident suggested an intervention for pain management during a care plan conference, but the facility failed to include it in her care plan. As a result, the resident experienced increased pain and reduced mobility. The social worker did not update the care plan or inform the staff, and the Director of Nursing acknowledged the oversight.
The facility failed to follow professional standards for hand hygiene and did not include specific interventions in the care plan for a resident with a stage 3 pressure injury. Improper hand hygiene was observed during wound care, and contaminated supplies were used. The baseline care plan lacked detailed interventions to promote healing or prevent worsening of the pressure injury.
The facility failed to provide appropriate catheter care and infection control for two residents. One resident's catheter was observed dragging on the floor, and another resident's catheter made contact with the floor multiple times during an adjustment. The DON confirmed that such practices are against infection control protocols.
A facility failed to ensure proper monitoring and emergency interventions for a resident with a dialysis fistula. The resident's care plan and MAR/TAR lacked necessary entries for monitoring the fistula, and staff were not adequately trained on emergency procedures for bleeding from the fistula.
A resident admitted with multiple health conditions was not weighed according to the facility's Weight Management policy, which required daily and weekly weigh-ins. The resident expressed concern about losing seven pounds since admission, and the Director of Nursing acknowledged the failure to follow weight orders, leading to a deficiency.
A resident with severe cognitive impairment and a history of multiple falls experienced eight falls within ten days. The facility failed to implement effective fall interventions and provide adequate supervision, resulting in a displaced right inferior pubic ramus fracture. Contradictory care plan interventions and the absence of a toileting schedule contributed to the deficiency.
Failure to Follow and Document Grievance Process for Resident Care Concerns
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to document grievances and prompt efforts to resolve them for a resident whose Activated Health Care Power of Attorney (AHCPOA) raised multiple concerns. The facility’s Grievance Program policy dated 5/15/24 states that grievances, defined as formal written or verbal complaints when prompt bedside resolution is not possible, must be documented on Comment/Concern Forms, routed to the grievance official, listed on the tracking log, discussed as warranted, and investigated accordingly. The policy also requires written grievance decisions to include dates, a summary of the grievance, corrective actions, and the date the written decision was issued to the complainant. The resident was admitted with diagnoses including cerebral infarction without residual effects and dysarthria/anarthria, and was on hospice services upon admission. Surveyors reviewed email communications from the AHCPOA to the Nursing Home Administrator (NHA) that listed specific concerns about the resident’s care, including the resident wearing dirty clothes, a full laundry bag, an unclean or unshaven face, a very red right eye needing more frequent eye drops, being found sitting unattended in the dining room while calling out for something to drink, lack of a mid-morning snack, difficulty obtaining coffee or juice, no juice cups in the room, eyeglasses found in the trash, and absence of hearing aids. When surveyors reviewed the facility’s grievance log, no grievance entry for this resident was found. In an interview, the NHA stated that when a grievance comes to her, she typically initiates a grievance form, works through what is needed, and follows up with the resident or family. However, regarding these concerns, the NHA acknowledged that due to the repetitive nature of the issues, she considered them part of day-to-day care rather than grievances, did not complete a grievance form, and had no documentation of investigation, follow-up, or resolution for the concerns raised, despite recognizing that she should have done so. As a result, the facility did not follow its grievance process.
Failure to Maintain Food Safety Standards and Proper Food Storage
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by multiple observations and interviews. Staff, including the Regional Maintenance Director and the Director of Nursing, were observed entering the main kitchen and kitchenette areas without wearing required hairnets, despite facility policy mandating hair restraints when working with food. During meal service, food was being prepared and served while staff were not in compliance with hair restraint policies. Surveyors found food items that had been removed from their original containers and were not labeled with use-by dates, as well as a dented can of jellied cranberry sauce in circulation. In the kitchenette freezer and refrigerator, there were uncovered and unlabeled food items, including opened containers of ice cream and sundae cups with ice crystals, as well as expired and undated food. The refrigerator and freezer temperature logs were incomplete, with several days missing recorded temperatures, and there was no clear assignment of responsibility for monitoring these temperatures. Additionally, the kitchenette cupboards contained unwrapped candy, dried substances, opened and expired food items, and food without proper labeling. Interviews with dietary, nursing, and housekeeping staff revealed confusion and lack of clarity regarding who was responsible for cleaning and monitoring the kitchenette areas, with no established policy or procedure in place for these tasks. These deficiencies had the potential to affect nearly all residents in the facility.
Failure to Provide Dignified Dining Experience Due to Use of Disposable Utensils and Cups
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were treated with dignity and respect during meal service, as required by federal and state regulations. Multiple observations revealed that residents, both in their rooms and in the main dining room, were consistently provided with plastic silverware and Styrofoam cups instead of regular metal utensils and glassware. This practice was noted to affect several residents, including those who were cognitively intact and able to express their preferences. Residents reported difficulty using plastic utensils to cut food and expressed a preference for regular silverware and cups, indicating that the use of disposables negatively impacted their dining experience. Interviews with staff, including CNAs, the Dietary Manager, and the Director of Nursing, revealed inconsistent knowledge and practices regarding the use of disposable versus regular dishware. Some staff stated that they used disposable items when regular supplies ran out, while others were unaware of the reason for using disposables. The Dietary Manager indicated that there was an adequate supply of regular dishware and utensils, and backup supplies were available, but staff did not always access them. The process for ensuring enough regular dishware and utensils were available for all residents was not clearly defined or consistently followed. The facility's policy on resident rights, which emphasizes the right to a dignified existence and respectful treatment, was not upheld in these instances. The lack of regular dishware and utensils, despite available supplies, led to residents being served meals in a manner that did not promote dignity or an enhanced quality of life. The deficiency was substantiated by direct observations, resident interviews, and staff statements, all indicating a systemic issue with the provision of appropriate dining materials.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
Multiple residents were found to be living in rooms that were not maintained in a safe, clean, comfortable, and homelike manner, as required by facility policy. Surveyors observed unmade beds, overflowing trash cans, dust bunnies, debris, and soiled items such as used gloves and adult incontinence products left on the floor. In several cases, residents' bathrooms were also found to be unclean, with dried stool on toilet seats and trash bags left on the floor. These conditions were confirmed by both staff and residents, who acknowledged that the rooms were not clean or homelike. Interviews with staff, including CNAs, housekeepers, and the Nursing Home Administrator, revealed a lack of a consistent cleaning schedule and inadequate documentation of when rooms were cleaned. Housekeeping staff reported that room cleaning frequency depended on staffing levels and workload, with some rooms not being cleaned for several days. Residents reported having to request cleaning, with some stating their rooms had not been cleaned since admission or that spills and debris remained for extended periods. One resident expressed embarrassment over the state of her room, especially when having visitors. The facility's own policy required regular cleaning of housekeeping surfaces and immediate cleaning when surfaces were visibly soiled. However, observations and interviews indicated that this policy was not being followed. The lack of a structured cleaning schedule and documentation system contributed to the ongoing unclean conditions in multiple residents' rooms, directly impacting their right to a safe and homelike environment.
Failure to Develop and Document Discharge Plan for Resident
Penalty
Summary
A deficiency was identified when the facility failed to develop a discharge plan for one of three residents reviewed for discharge planning. The facility's policy requires that each resident's comprehensive care plan be consistent with their rights to participate in the development and implementation of their care, including establishing goals and outcomes. The resident in question was admitted with diagnoses including paraplegia, anxiety disorder, PTSD, and recurrent depressive disorders, and was found to be cognitively intact and his own decision maker. Despite these factors, there was no documentation of a care conference or a discharge care plan in the resident's medical record. During interviews, the resident confirmed that no one had discussed discharge planning with him and that he had not participated in a care conference. The social worker explained that the usual process involves setting up a care conference within 5-7 days of admission and another meeting 1-2 weeks later to address equipment and support needs, with documentation under the assessments tab. However, upon review, both the surveyor and the social worker confirmed that there was no documentation of a care conference or discharge care plan for this resident, indicating a failure to follow the facility's established discharge planning process.
Failure to Provide Appropriate Catheter Care and Privacy
Penalty
Summary
The facility failed to provide appropriate care and services for residents with indwelling catheters, as evidenced by two specific cases. In the first case, a resident with moderate cognitive impairment and multiple diagnoses, including anxiety disorder, major depressive disorder, and heart failure, had an indwelling catheter placed without an appropriate supporting diagnosis. The resident's physician order indicated the catheter was for hospice/comfort, but there was no documented care plan addressing the catheter, and the Director of Nursing was unable to immediately provide the rationale or documentation for its use beyond referencing hospice notes. In the second case, another resident with a Foley catheter had a care plan specifying that the catheter bag and tubing should be positioned below the bladder and away from the entrance room door or covered for privacy. However, the catheter bag was observed hanging on the bed frame, facing the door, and visible from the hallway without a cover. The CNA responsible for the resident's care confirmed that the bag was not covered or repositioned as required, and the Director of Nursing acknowledged that the care plan interventions were not followed.
Failure to Provide Trauma-Informed, Culturally Competent Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with PTSD. Upon review, it was found that the resident, who has a history of paraplegia, anxiety disorder, PTSD, and recurrent depressive disorders, did not have a complete trauma assessment or a care plan addressing their PTSD diagnosis, triggers, or specific interventions. The resident's most recent MDS indicated cognitive intactness and some social isolation, but the care plan lacked any reference to PTSD or trauma-related needs. Further investigation revealed that the trauma history evaluation for the resident was only partially completed, with only two out of six sections fully filled out. During an interview, the facility's social worker confirmed that the process for residents with PTSD should include a complete trauma assessment and a care plan addressing trauma, triggers, and interventions. However, the social worker acknowledged that these steps were not completed for this resident, resulting in a deficiency in providing care that is trauma-informed and culturally competent as required by facility policy.
Failure to Label Multi-Dose Tuberculin Vial in Medication Room
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were properly labeled in accordance with professional standards. Specifically, an open vial of Tuberculin solution was found in the medication room refrigerator without an open date or expiration date, contrary to the facility's policy requiring multi-dose vials to be dated and discarded within 28 days unless otherwise specified by the manufacturer. During interviews, a registered nurse confirmed that the vial should have been dated and acknowledged that it should be discarded if not properly labeled, stating that responsibility for dating medications is shared among staff. The Director of Nursing was unaware of the issue and believed the vials were single-use, but the facility’s pharmacy confirmed that all Tuberculin vials provided are multi-dose.
Failure to Maintain and Coordinate Hospice Documentation and Care Plan
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services had appropriate hospice documentation and a coordinated care plan in accordance with professional standards of practice. The resident, who had diagnoses including anxiety disorder, major depressive disorder, and acute on chronic heart failure, was admitted to the facility already enrolled in hospice. Despite this, the facility did not have documentation of the resident's hospice enrollment, admission assessment, care plan, orders, or visit notes in the electronic health record. Additionally, there was no facility-generated care plan addressing hospice for the resident prior to the surveyor's inquiry. Interviews with facility staff revealed inconsistent processes for obtaining and storing hospice documentation. The RN stated that hospice care plans and visit notes should be faxed and scanned into the EHR, but only one hospice note was found, and no care plan was available. The DON indicated that hospice documentation should be available in binders on the unit, but was only able to provide the required documents after the surveyor's request. The hospice nurse confirmed that routine visit notes were not regularly faxed to the facility and that the care plan and visit notes were only sent after a recent request. This lack of timely and accessible hospice documentation resulted in the facility not meeting its policy requirements for coordinated care for residents on hospice.
Failure to Maintain Infection Control Precautions for Residents on Isolation and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple breaches in transmission-based precautions for two residents. In one instance, a resident with a confirmed diagnosis of COVID-19 was placed on droplet precautions, with appropriate signage and PPE supplies available outside the room. However, a Licensed Practical Nurse (LPN) was observed entering the resident's room without wearing any required personal protective equipment, including a mask, gown, gloves, or eye protection, despite being aware of the resident's COVID-19 status and the need for such precautions. Both the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), who also serves as the infection preventionist, confirmed that proper PPE should have been used in this situation. In another case, a resident with a tracheostomy was under enhanced barrier precautions, as indicated by signage and a PPE cart outside the room. During tracheostomy care, a Registered Nurse (RN) performed hand hygiene initially but then set up care supplies with bare hands and failed to don a gown, as required. The RN removed and replaced gloves multiple times during the procedure without performing hand hygiene between glove changes, only doing so at the end of the care. The RN acknowledged not following proper hand hygiene protocols and not wearing a gown, both of which were required by facility policy for this type of care. Interviews with the ADON confirmed that hand hygiene should have been performed after each glove removal and that enhanced barrier precautions, including the use of gown and gloves, were necessary for tracheostomy care. The facility's own policies, as well as physician orders, outlined these requirements, but staff failed to adhere to them during the observed care activities.
Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to ensure thorough investigations of alleged abuse, neglect, and mistreatment for four out of five residents reviewed. In one case, a resident with severe cognitive impairment was found to have labial bruising and vaginal tears of unknown origin while hospitalized. The facility's investigation did not address discrepancies in transportation times, did not include all relevant staff interviews, and failed to conduct or document comprehensive skin assessments for all residents following the incident. Additionally, the investigation lacked documentation of education or competency checks for transport drivers and did not include interviews with contracted hospice nurses. Another resident, who was cognitively intact, reported not receiving pain medication and assistance despite repeated requests, leading to distress and a grievance report. The facility's documentation did not include interviews with other residents about missed care, education provided to staff, or records of follow-up support. The investigation file was incomplete, and key documentation such as staff interviews and education records could not be located by facility leadership. Additional deficiencies were noted in the handling of a resident's report of neglect and rough care, as well as a verbal altercation between a resident and a family member. In both cases, the facility failed to document thorough investigations, including interviews with involved parties, skin assessments, and staff education. Facility leadership acknowledged during interviews that the investigations were incomplete and lacked supporting documentation, failing to meet the requirements outlined in the facility's own abuse prevention policies.
Failure to Monitor Medication and Document Weights Leads to Resident Harm
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice for three residents, leading to significant health complications. Resident R3, who was admitted with congestive heart failure, was prescribed Furosemide, a diuretic known to cause potassium and sodium depletion. Despite this, the facility did not monitor R3's electrolyte levels or provide potassium supplementation, resulting in critically low sodium and potassium levels and subsequent hospitalization. Additionally, the facility did not discontinue Furosemide as ordered upon R3's readmission, further exacerbating the resident's condition. The facility also failed to consistently monitor and document the weights of residents R1 and R3 as per physician orders. R3's daily weights were not recorded on numerous occasions, which was crucial for managing his heart failure condition. Similarly, R1 missed several scheduled weight checks, which were part of the physician's orders to monitor the resident's health status. These lapses in documentation and monitoring increased the risk of health complications for the residents. Interviews with facility staff revealed systemic issues in the handling of physician orders and documentation. The Assistant Director of Nursing admitted to personal issues affecting the processing of transfer orders, leading to medication errors. The Director of Nursing acknowledged that while CNAs were responsible for taking weights, the nurses often failed to document them in the electronic medical record. These failures in communication and documentation contributed to the deficiencies observed in the care of the residents.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nurse staffing to meet the needs of its residents, compromising their safety and well-being. The facility's assessment indicated a need for specific staffing levels based on resident acuity and census, including one Nurse Manager on the first shift, one RN/LPN on each shift, and one to three CNAs on the first and second shifts. However, the staffing schedule from January 9 to January 11 revealed significant gaps, with instances of missing RNs or LPNs on shifts and CNAs not showing up for work, leading to understaffed shifts. Interviews with residents and family members highlighted the impact of inadequate staffing, with reports of delayed response times to call lights and residents experiencing incontinence due to long waits for assistance. One resident, who was cognitively intact, reported a 22-minute wait for help to use the bathroom. Family members expressed concerns about insufficient staff, particularly during evening and night shifts, resulting in unmet needs and prolonged wait times for assistance. Staff interviews corroborated these concerns, with CNAs and other staff members acknowledging the challenges of managing resident care with insufficient staffing. They reported being overwhelmed with tasks such as answering call lights, providing showers, and ensuring residents were fed. The Assistant Director of Nursing and other staff members agreed that the facility was not adequately staffed to meet the residents' needs, despite the facility's claim of exceeding state minimum requirements. The Regional Clinical Nurse noted that staff were not being utilized effectively, further contributing to the deficiency.
Incomplete Documentation and Communication During Resident Transfer
Penalty
Summary
The facility failed to properly document and communicate necessary information during the transfer of a resident to a hospital. The resident, who was admitted with T-cell lymphoma, skin cancer, and diabetes, was transferred due to generalized weakness, failure to thrive, and worsening skin condition. The physician recommended hospital transfer for diagnostic and lab testing, with a potential helicopter transfer to Rochester, MN for further care. However, the transfer documentation was incomplete, lacking critical information about the resident's condition, including respiratory status, skin/wound care, and rehabilitation therapy. Additionally, the transfer form did not include essential documents such as a face sheet, personal belongings list, current medication list, advanced directives, recent medical history, and relevant x-ray results. The Regional Clinical Nurse acknowledged that the transfer form was not fully completed, which was against the facility's expectations. This oversight in documentation and communication could have impacted the continuity of care for the resident during the hospital transfer.
Failure to Provide ADLs According to Care Plan
Penalty
Summary
The facility failed to provide activities of daily living (ADLs) according to the care plan for a resident (R5) who was admitted with diagnoses including adult failure to thrive and a need for personal care. The care plan indicated that R5 required extensive assistance for bathing and dressing, and limited assistance for personal hygiene. However, observations revealed that R5 was not receiving the necessary care, as evidenced by her unkempt appearance, including greasy hair, long chin and lip hair, and wearing the same clothes over consecutive days. The facility's records showed no documented showers for R5 since her admission, and interviews with staff indicated a lack of clarity and communication regarding the provision of showers and personal care. Interviews with the CNA and OT revealed that R5 had refused some personal care activities, such as sponge baths, but there was no documentation of these refusals in the point of care (POC) system. The CNA admitted to not providing a shower to R5 and was unaware of the protocol for addressing the lack of clothing or notifying the family. The Assistant Director of Nursing (ADON) confirmed the observations of R5's appearance and acknowledged the need for family involvement in providing additional clothing. The Director of Nursing (DON) highlighted issues with staff documentation practices, emphasizing the need for accurate recording of care refusals.
Failure to Monitor and Communicate Wound Care for Resident
Penalty
Summary
The facility failed to consistently assess and monitor pressure ulcers and wounds for a resident, identified as R4, who was admitted with multiple wounds, including a stage 3 pressure ulcer, a deep-tissue injury, and a scalp burn. Upon admission, the facility's documentation did not include measurements or assessments of R4's wounds, and there was a lack of timely wound evaluation, as the Director of Nursing only assessed the wounds six days after admission. Additionally, the facility did not document any updates to the provider regarding the resident's wounds. R4 refused wound care on multiple occasions, stating that dressings did not need to be changed if they were not bleeding. Despite the resident's refusal, there was no documentation indicating that the provider was notified of these refusals. The facility's policy required notification of the supervisor and provider when a resident refused wound care, but this was not adhered to in R4's case. Furthermore, there was an inconsistency in the wound care provided, as Medi-honey was applied to the scalp wound instead of the prescribed Silvadene. The facility's failure to document and communicate effectively about R4's wound care and refusals resulted in a lack of proper monitoring and assessment. The Regional Clinical Nurse confirmed that the assessment and monitoring of the wounds were not conducted, and the provider was not informed of the resident's refusal to have wound care performed. This lack of adherence to the facility's wound care policy and procedures contributed to the deficiency identified in the report.
Medication Timing Error for Resident with Parkinson's
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R6, who did not receive his Trazadone medication according to his preference and physician's orders. R6, who was admitted with diagnoses including a left leg fracture, Parkinson's disease, and dementia, had a BIMS score indicating he was cognitively intact. His physician's orders specified that Trazadone, an antidepressant, should be administered at 6:00 PM, with a special precaution to give the medication between 6:30 PM and 7:00 PM due to his preference to go to bed around 7:00 PM. On two occasions, R6's medication was administered late. On one occasion, the medication was given after 7:30 PM, and on another, it was administered at 7:15 PM by an agency nurse unfamiliar with the resident's needs. This delay in medication administration was confirmed by the Regional Clinical Nurse, who acknowledged that the medications were not given according to the special precautions banner. The resident's family member, FM1, expressed concerns about the timing of the medication and reported these issues to the Regional Nurse, who provided his contact information for further issues.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents, R1 and R4, which placed them at risk of unmet care needs. For R1, who was admitted with diagnoses including T-cell Lymphoma, skin cancer, and diabetes, the facility did not document skin/wound assessments in the daily Medicare and/or Skilled Charting documentation from 11/14/24 to 11/18/24. Despite having a stage four pressure ulcer on the sacrum, an unstageable pressure ulcer on the scrotum, and a deep-tissue injury on the heels, there was no documentation in the Nursing Progress Notes regarding these conditions. The Assistant Director of Nursing (ADON) acknowledged the lack of documentation and stated that any out-of-the-ordinary conditions should have been recorded. Similarly, for R4, who was admitted with colon cancer, stage 3 ulcers, and diabetes, the facility failed to complete the required daily Medicare and/or Skilled Charting documentation on several occasions, including 12/25/24, 12/30/24, 01/04/25, 01/05/25, and 01/09/25. R4 had a stage 3 pressure ulcer, a deep-tissue injury, and was receiving intravenous antibiotic therapy for a wound infection. The ADON confirmed that the Medicare and/or Skilled Charting documentation should be completed daily and updated with any new issues the resident develops.
Deficiencies in Food Safety and Hand Hygiene
Penalty
Summary
The facility did not maintain a safe and sanitary environment for food preparation, storage, and distribution, affecting all 12 residents. Staff were observed working in the kitchen without beard nets, contrary to the facility's policy. Chef Q was seen placing dirty pans in a rack and then handling clean pans without washing his hands or wearing gloves, and the metal pans were wet stacked on a drying rack. Additionally, the thermometer probe was not sanitized between temping resident food, and Chef Q was observed putting garbage and gloves in the garbage can without washing his hands before returning to cooking. KM P was also observed dishing up lunch with gloves on, making a phone call, and then returning to the steam table with the same gloves on. Undated food items were found in the cook's refrigerator and the first-floor kitchenette, and Lead Activity Assistant E served lunch to residents with soiled gloves on, touching various surfaces without washing hands or changing gloves. The facility's policies on hair restraints, dishwashing, thermometer sanitization, hand washing, and food labeling and dating were not followed. Chef Q and DA R were observed preparing food without beard nets, and Chef Q did not follow proper hand hygiene and glove use when handling dirty and clean dishes. The thermometer probe was not disinfected between uses, and Chef Q did not wash his hands after handling garbage. KM P did not change gloves or wash hands after making a phone call before continuing to dish up lunch. Undated food items were found in multiple locations, and Lead Activity Assistant E did not follow proper hand hygiene while serving food to residents. Residents R2 and R4 were directly affected by the deficiencies in hand hygiene and food handling. Lead Activity Assistant E served their lunch with soiled gloves, touching various surfaces without washing hands or changing gloves. Interviews with staff, including KM P, RN G, and DON B, confirmed that proper procedures were not followed, and there was a lack of adherence to the facility's policies on hand hygiene and food handling. The deficiencies observed have the potential to impact the health and safety of all residents in the facility.
Inaccurate PBJ Reporting and Staffing Deficiencies
Penalty
Summary
The facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS). This deficiency has the potential to affect all 12 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting, triggering deficiencies for two fiscal year quarters for failure to have licensed nursing coverage 24 hours a day and one fiscal year quarter for failure to have Registered Nurse (RN) hours each day. The CMS's PBJ Staffing Data Report for fiscal year quarter 3 of 2023 indicated that the facility failed to have licensed nursing coverage 24 hours a day on multiple dates, with specific instances of less than 24 hours of coverage reported. Similarly, for fiscal year quarter 4 of 2023, the facility again failed to maintain 24-hour licensed nursing coverage on several dates and also failed to have RN hours on multiple days within the quarter. The CASPER Report 1702D and 1705D corroborated these findings, showing specific dates with insufficient licensed nursing and RN hours. During an interview, the Nursing Home Administrator (NHA) stated that the PBJ reporting was done correctly and that there was licensed coverage 24 hours a day. However, the NHA and Corporate Consultant were unable to reach the facility's accountant, who is responsible for the final report submission to CMS, during the survey period. The NHA provided documentation, including time punches and schedules, to prove that there was 24-hour licensed nurse coverage and RN coverage on the infraction dates, but the CASPER Report did not reflect this information.
Infection Control Deficiencies
Penalty
Summary
The facility did not establish and maintain an effective infection prevention and control program, which has the potential to affect all 12 residents. Staff were allowed to return to work too soon after reporting gastrointestinal symptoms and were not placed on the line list for respiratory symptoms. The facility failed to accurately document employees' symptom onset and did not evaluate whether staff should be working based on their symptoms. Additionally, the facility did not require staff to be tested for other communicable illnesses such as RSV or Influenza during cold and flu season. During an observation, a CNA performed catheter care on a resident with chronic kidney disease and urinary retention without appropriate hand hygiene. The CNA repeatedly changed gloves without performing hand hygiene, handled clean and dirty items interchangeably, and applied barrier cream without changing gloves. This improper technique was confirmed during an interview with the CNA, who admitted to not performing hand hygiene as required. The facility's policies were not followed, as evidenced by the lack of proper documentation and tracking of staff symptoms and the failure to ensure staff stayed home for the appropriate amount of time after symptoms resolved. The Director of Nursing confirmed that hand hygiene should be performed between cleansing, rinsing, and drying, which was not done in this case.
Failure to Provide Necessary ADL Services
Penalty
Summary
The facility failed to ensure that five residents received the necessary services to maintain good nutrition, grooming, personal, and oral hygiene. Residents R1, R115, R4, R9, and R65 did not receive showers as scheduled, which was confirmed through observation, interviews, and record reviews. R1, who is cognitively intact, reported feeling grungy due to not receiving showers as scheduled. Documentation showed that R1 did not receive the required two showers per week as indicated in the care plan. Similarly, R115 and R4 also did not receive the scheduled showers, and R9 reported feeling like she smelled due to the lack of showers. The documentation for R9 showed multiple instances of missed showers or lack of proper documentation for refusals or unavailability. R65, who has multiple diagnoses including Parkinson's disease and dysphagia, was observed being left without food while his tablemates ate. When he was finally given food, he was not provided with utensils and had to use his fingers to eat. His plate was then moved out of his reach, and he was left to sit and watch others eat for 29 minutes before being assisted. This was contrary to his care plan, which stated that he should be allowed to participate in feeding as much as possible. The facility's policy on Activities of Daily Living, dated 6/29/21, states that residents who are unable to carry out activities of daily living should receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. However, the facility failed to adhere to this policy, resulting in residents not receiving the care they needed. Interviews with staff, including the Director of Nursing, confirmed that the expectation was for residents to receive showers twice a week and for all care and refusals to be documented, which was not consistently done.
Deficiency in Providing Resident-Centered Activity Programs
Penalty
Summary
The facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This deficiency affected seven residents who were reviewed for activities. The facility failed to incorporate social history assessment information into the care plans of these residents, resulting in care plans that were not person-centered. Residents voiced concerns about the lack of activity programming, and the facility did not create personalized care plans that included information collected during initial assessments, such as social history, familiar routines, past and present interests, and other personalized important information. For example, one resident, who was cognitively intact, had an activities assessment that included detailed personal information but did not have an activities care plan in their comprehensive care plan. Another resident with moderate cognitive impairment had a care plan that was not individualized or resident-centered, and the resident reported that there were no activities available. The facility's activity attendance records showed that the activities primarily consisted of reading a newsletter and occasional group activities, which were not aligned with the residents' interests and preferences. The facility's staff, including the Lead Activity Assistant and the Social Worker, acknowledged that the care plans should reflect the information gathered during initial assessments and be individualized to each resident's preferences, wants, and needs. However, the care plans reviewed did not include personalized interventions or measurable goals related to activities. The facility also failed to review activity attendance data to determine the effectiveness of the activity program for each resident. The Lead Activity Assistant lacked the qualifications and training to run the activity program effectively, and the Social Worker was overseeing the program without adequate involvement in the activity department.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, affecting three residents in the dining area. One resident, who has multiple diagnoses including Parkinson's disease and cognitive communication deficit, was observed with uncombed hair, an unshaven face, and an uncovered catheter bag. This resident was seated at a table with other residents who were eating, but he was not given silverware and had to wait 29 minutes before receiving assistance with his meal. During this time, staff talked about the resident's altered diet and exposed catheter in front of him and other residents, further compromising his dignity. Another resident, who depends on staff for some needs and has a catheter, was observed in the dining area with her catheter bag uncovered, exposing the urine inside. This resident expressed a preference for the catheter bag to be covered when out of her room. Despite this, the catheter bag remained uncovered during the observation period. A third resident, who has diagnoses including bladder cancer and moderate cognitive impairment, was also observed with an uncovered catheter bag in the dining area. Staff acknowledged that catheter bags should be covered for both infection control and dignity reasons, but the resident's catheter bag was not covered until after the surveyor's observation. These incidents demonstrate a failure to uphold the residents' rights to dignity and respect as outlined in the facility's policies and federal regulations.
Failure to Include Resident's Suggested Pain Management Intervention in Care Plan
Penalty
Summary
The facility failed to ensure that a resident or their representative had the right to participate in the care planning process. Specifically, a resident (R2) attended a care plan conference and suggested an intervention to aid in her pain management during transfer, bed mobility, and toileting. However, this intervention was not considered when revising R2's care plan. As a result, R2 indicated she no longer gets out of bed due to staff not following the suggested intervention. The social worker (SW T) did not add the suggested intervention to R2's care plan and did not inform the front-line staff about it. R2 was admitted to the facility with multiple diagnoses, including a wedge compression fracture of the second lumbar vertebra, low back pain, and chronic kidney disease stage 3. Despite R2's comprehensive care plan addressing her pain management, the specific intervention she suggested during the care plan conference was overlooked. Interviews with R2 and staff confirmed that the intervention was not added to the care plan, and staff were not educated on implementing it. The Director of Nursing (DON B) acknowledged that the intervention should have been added and staff should have been educated on slower transfers and other activities of daily living (ADLs).
Failure to Implement Proper Hand Hygiene and Care Plan for Pressure Injury
Penalty
Summary
The facility failed to implement professional standards of practice to promote healing or prevent pressure injury (PI) development for a resident with a stage 3 PI of the sacral region. During wound care, improper hand hygiene techniques were observed, including the failure to perform hand hygiene after closing the resident's door, assisting the resident into bed, and touching the bed remote. Additionally, the nurse used contaminated 4 x 4 gauze pads and did not perform hand hygiene between glove changes, which is against the facility's hand hygiene policy dated August 2019. The resident's baseline care plan did not include specific interventions or goals related to the stage 3 PI, which is a violation of the facility's policy on baseline care plans dated December 2016. The care plan only mentioned maintaining universal precautions and following facility protocols for treatment but lacked detailed interventions to promote healing or prevent the worsening of the PI. This omission put the resident at risk of worsening the existing PI and developing new PIs. Interviews with the RN and DON confirmed the observed deficiencies. The RN acknowledged the failure to perform hand hygiene at critical points during wound care and admitted to using contaminated supplies. The DON also confirmed that hand hygiene should have been performed at the specified times and that contaminated supplies should not have been used. Both the RN and DON agreed that the baseline care plan should have included specific interventions to address the resident's stage 3 PI.
Inadequate Catheter Care and Infection Control
Penalty
Summary
The facility did not ensure that residents with catheters received appropriate treatment and services to prevent urinary tract infections. For Resident 113, who has diagnoses including bladder cancer and benign prostatic hyperplasia, the catheter drainage port was observed dragging on the floor during a transfer in a wheelchair. The CNA responsible for Resident 113 acknowledged that the catheter should not be dragging on the floor and adjusted it after being prompted by the surveyor. The Director of Nursing confirmed that catheters should not touch the floor due to infection control concerns. For Resident 9, who has diagnoses including malignant neoplasm of the kidney and cognitive communication deficit, the catheter was observed without a cover, exposing the urine inside. During the process of attaching a dignity bag to the wheelchair, the catheter made contact with the floor three times. The Director of Nursing confirmed that catheter bags should not be in direct contact with the floor. These observations indicate a failure to maintain proper catheter care and infection control practices for residents with catheters.
Failure to Monitor Dialysis Access Sites and Provide Emergency Interventions
Penalty
Summary
The facility did not ensure that a resident requiring dialysis received services consistent with professional standards of practice. The resident, who had diagnoses including end-stage renal impairment and hypertensive chronic kidney disease, had a chest port and an arteriovenous fistula in her arm. The facility's policy required monitoring of the dialysis access sites, but the resident's Medication Administration Record/Treatment Administration Record (MAR/TAR) did not include entries for monitoring the fistula every shift, including palpating the site to feel the thrill and using a stethoscope to hear the bruit of blood flow through the access. Additionally, the resident's Comprehensive Care Plan did not include interventions for emergency care if the resident was found to be bleeding from her fistula. Interviews with the resident and staff revealed that the staff did not regularly monitor the resident's fistula. The resident indicated that staff did not look at her arm, and a Certified Nursing Assistant (CNA) was unsure of the actions to take if the resident was found bleeding from her fistula. A Registered Nurse (RN) confirmed that the MAR/TAR only included monitoring of the chest port and that the fistula should also be monitored every shift. The Director of Nursing (DON) acknowledged that the care plan should include emergency interventions for the fistula and that staff should apply pressure and not leave the resident alone if bleeding occurred. The deficiency was further evidenced by the lack of documentation and training regarding the monitoring and emergency care of the resident's fistula. The DON and RN indicated that the necessary interventions and monitoring should have been in place and documented, but they were not. This oversight left the resident at risk for complications related to her dialysis access sites, as staff were not adequately prepared to handle potential emergencies involving the fistula.
Failure to Adhere to Weight Management Policy for New Admission
Penalty
Summary
The facility failed to adhere to its Weight Management policy for a new admission, resulting in a deficiency. A resident, identified as R4, was admitted with multiple health conditions, including rib fractures, muscle weakness, and cerebrovascular disease. The facility's policy required that new admissions be weighed the morning after admission and daily for two days, followed by weekly weigh-ins for four weeks. However, R4's weight was not recorded according to these standards. The only documented weights were from the resident's History and Physical, dated 4/21/24, showing 240 pounds, and a subsequent weight on 5/15/24, showing 233.6 pounds. R4 expressed concern about losing seven pounds since admission, which was confirmed by the surveyor's review of the medical records. The Director of Nursing (DON) acknowledged that the weight orders were not followed and admitted that an admission weight was necessary to assess the resident's condition accurately. The failure to obtain and document weights as per the facility's policy and physician orders led to the deficiency identified by the surveyor.
Inadequate Supervision and Fall Prevention
Penalty
Summary
The facility did not ensure adequate supervision and safety to prevent accidents for a resident with a history of multiple falls. The resident, who was severely cognitively impaired and had a BIMS score of 00, experienced eight falls within a ten-day period. Despite the resident's high fall risk and multiple falls, the facility failed to implement effective fall interventions and provide adequate supervision. The resident's care plan included interventions such as keeping the bed at knee height and using a low bed, which contradicted each other. Additionally, the facility did not include a toileting schedule in the care plan, despite evidence suggesting that the resident was attempting to use the bathroom during several falls. The facility's fall reports consistently indicated
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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 Janesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Elizabeth Nursing Home | 1.7 mi | ★★★★★ | 19 | 0 |
| Mercy Manor Transition Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Rock Haven | 2.6 mi | ★★★★★ | 8 | 0 |
| Cedar Crest Health Center | 3.4 mi | ★★★★★ | 4 | 0 |
| Beloit Health And Rehabilitation Center | 8.6 mi | ★★★★★ | 19 | 0 |
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