Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Odd Fellow Home during CMS and state inspections, most recent first.
A resident with post-hip arthroplasty, osteoarthritis, and atrial fibrillation had a clarified order for Eliquis to be given at 2.5 mg BID for one week, then increased to 5 mg BID. Although the clarification was documented and the family was informed, staff continued to administer 2.5 mg BID for an additional day, and the MAR showed the 5 mg BID dose was not started until the following day. This discrepancy, attributed by the NHA to a possible transcription error, resulted in two incorrect Eliquis doses and was not consistent with the facility’s medication administration policy requiring adherence to prescriber orders.
The facility did not report two separate allegations of abuse involving two residents to the State Agency as required. In one case, a resident's abuse-related fall investigation was not submitted within the mandated timeframe, and in another, a resident's report of rough handling by a CNA was handled as a grievance but not reported to the SA.
Two residents' abuse allegations were not thoroughly investigated, as required by facility policy. In one case, a resident's fall determined to be abuse lacked statements from the involved CNA and LPN, and staff education did not match the resident's care plan. In another case, a resident reported being manhandled by a CNA, but the investigation was incomplete, missing root cause analysis, interviews, and documentation of staff education.
A resident with multiple medical conditions, including epilepsy, did not receive scheduled AM and PM medications within the required time frame on several occasions. Facility policy requires medications to be administered within one hour of the prescribed time, but MAR review and staff interviews confirmed repeated late administration, and the resident reported ongoing concerns about medication delays.
A resident with severe cognitive impairment, muscle weakness, and a history of repeated falls did not consistently receive prescribed fall prevention interventions, including 15-minute safety checks and grip strips at the bedside. Staff failed to complete safety checks for several hours, during which the resident experienced an unwitnessed fall with injury. Observations and staff interviews confirmed that interventions were not reliably implemented or documented, despite facility policy and the resident's high risk status.
The facility did not have a qualified IP overseeing the infection prevention and control program, as neither the interim IP nor the DON had completed required specialized training. During this period, staff returned to work before meeting CDC recommendations after COVID-19 or GI illness, and the facility lacked policies specifying IP training requirements or hours needed for the role.
Surveyors found that medications and biologicals were not consistently labeled, dated, or stored according to policy. Multiple medications, including inhalers, insulin, and eye drops, were found without open dates or labels, and expired medications and supplies were present in storage areas and on medication carts. Staff, including LPNs and the DON, confirmed these deficiencies during interviews, acknowledging that medications should be dated when opened and expired items should be removed.
Multiple staff failed to use appropriate PPE and follow infection control protocols during care of residents on enhanced barrier precautions, including wound care and equipment sanitation. Additionally, staff returned to work after COVID-19 or GI illness earlier than CDC and state guidelines recommend, with incomplete documentation of symptom resolution.
Two residents with suspected serious mental illness were granted 30-day hospital exemptions on their PASRR Level I Screens, but the facility did not submit the required PASRR Level II Screens after the exemptions expired. One resident had anxiety disorder and was not cognitively impaired, while the other had multiple mental health diagnoses and moderate cognitive impairment. The Admissions Coordinator confirmed the oversight.
A resident receiving hemodialysis was not consistently monitored for bruit/thrill as required by facility policy, and there was a lack of ongoing communication between facility staff and the dialysis center. Staff interviews revealed that daily monitoring was not documented, and there was confusion about what information was exchanged with the dialysis center, resulting in incomplete records and missing aftercare instructions.
A nurse administered Senna-Plus, a combination laxative, instead of the prescribed Senna to a resident during a medication pass. Facility policy requires staff to verify medications against prescriber orders, but this step was not followed, resulting in the resident receiving the incorrect medication.
Three residents received antibiotics without meeting McGeer's criteria for infection, and prescribers were not notified of the lack of qualifying signs or symptoms. The facility did not follow its own antibiotic stewardship policies, resulting in inappropriate antibiotic use for urinary, skin, and respiratory infections.
The facility failed to update care plans for three residents regarding the use of Hoyer slings, which were left under residents in Geri chairs and wheelchairs, contrary to facility policy. Despite the policy requiring sling removal, staff routinely left them in place, and care plans lacked necessary updates. Observations and interviews confirmed this practice, with residents reporting no discomfort, but the facility's policy was not followed.
A resident with hemiplegia and an acquired absence of the right leg was left hanging in a lift due to a dead battery during a transfer. Staff interviews revealed that lift batteries often died mid-transfer, and staff did not consistently check battery life. The facility had ordered new batteries, but only one was observed in the charger. The Nursing Home Administrator confirmed that staff should use a manual release to lower residents if a battery dies, but this was not done, resulting in the resident being left suspended.
Two residents with indwelling catheters had their catheter drainage bags improperly placed in contact with the floor, contrary to the facility's policy. One resident's bag was on the floor due to the bed's position, while another's bag was dragging on the floor from their wheelchair. Staff confirmed the improper placement, highlighting a lapse in infection control procedures.
A resident with type 2 diabetes on a CCHO diet received a full piece of cake instead of the prescribed half piece. The dietary staff provided the larger portion based on the resident's preference, despite the meal ticket indicating a smaller serving. The facility lacked a policy to ensure adherence to prescribed diets, leading to this inconsistency.
A resident on Enhanced Barrier Precautions did not receive proper infection control measures as staff failed to wear PPE during high-contact care and did not disinfect equipment after use. Despite the resident's significant medical history, including severe sepsis and open wounds, staff did not adhere to the facility's infection control policies.
The facility failed to timely report and investigate an altercation between two residents, one with intact cognition and another with severe cognitive impairment. The incident was not reported to administration promptly, leading to a delay in notifying the State Agency. Additionally, there was no proof of education for certain staff on duty during the incident, indicating a lapse in staff training on reporting requirements.
The facility failed to ensure proper disposal of garbage and refuse in outside dumpsters. During a kitchen tour, three dumpsters were found with open lids and garbage on the ground. The Dietary Manager acknowledged the issue but did not take immediate action to remove the garbage.
The facility failed to honor the meal preferences of six residents, providing meals that did not match dietary plans or preferences. Staff made assumptions about residents' choices without consulting them or their power of attorney for healthcare.
The facility failed to provide timely written transfer notices to three residents and did not notify the State Long-Term Care Ombudsman of these transfers. The residents were transferred to the hospital for various medical reasons, but the required documentation and notifications were not completed as per the facility's policy.
The facility failed to provide three residents with written information regarding the bed hold policy when they were transferred to the hospital. This deficiency was confirmed by the Assistant Nursing Home Administrator and the Nursing Home Administrator, who indicated that nurses are expected to provide this information but did not do so in these cases.
The facility failed to ensure resident safety and proper fall management by using defective equipment, not completing fall assessments, and not updating care plans with new interventions. Despite warnings, a lift with broken brakes and a defective sling was used, and neurochecks were not completed as required.
A resident with obstructive sleep apnea was provided with CPAP therapy without a physician's order, and the need for and use of CPAP therapy was not included in the care plan. The facility's policies for CPAP therapy and infection prevention were not followed, as evidenced by the lack of labeling on the CPAP machine's tubing and inconsistent staff education on the CPAP mask/machine.
The facility failed to ensure proper monitoring of a high-risk medication for a resident with diabetes mellitus. The resident's care plan lacked interventions to monitor for hypoglycemia and hyperglycemia, despite having physician orders for both short-acting and long-acting insulin. The deficiency was confirmed through a medical record review and an interview with the DON.
Failure to Accurately Transcribe and Implement Eliquis Dose Change
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate medication administration for one resident when staff did not follow the prescriber's clarified order for Eliquis dosing. The resident was admitted with diagnoses including post-hip arthroplasty, osteoarthritis, atrial fibrillation, and panic disorder, and had an MDS BIMS score of 15/15 indicating intact cognition. Hospital discharge paperwork ordered Eliquis 5 mg twice daily for DVT prevention, with instructions to give 2.5 mg twice daily for the first seven days post-operatively. A subsequent physician communication on 12/23/25 clarified that the resident should receive Eliquis 2.5 mg twice daily through 12/25/25 and 5 mg twice daily starting on 12/26/25, and a nursing note documented that the order was changed accordingly and the family was updated. Despite this clarification and documentation, the December MAR showed that the resident continued to receive Eliquis 2.5 mg twice daily from 12/19/25 through 12/26/25, totaling eight days at the lower dose, and the 5 mg twice daily dose was not started until 12/27/25. This resulted in the resident receiving two incorrect doses of Eliquis on 12/26/25, contrary to the prescriber's order and the facility's Administering Medications policy, which requires medications to be administered in accordance with prescribers' orders. During interview, the NHA confirmed that the Eliquis dose should have been increased on 12/26/25 and acknowledged that a transcription error may have occurred when the order was entered.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency (SA) for two residents as required by policy and federal regulations. In the first instance, a resident with multiple diagnoses including dementia, Huntington's disease, and repeated falls experienced a witnessed fall. The Interdisciplinary Team determined that abuse had occurred based on the LPN's progress note. While the initial report was submitted to the SA on the day of the incident, the required 5-day investigation report was not submitted within the mandated timeframe, as the Nursing Home Administrator delayed submission while waiting for an additional staff statement. In the second instance, another resident with intact cognition and a history of congestive heart failure, respiratory failure, and falls reported to staff that a CNA was abusive during care, describing rough handling and feeling unsafe. The facility initiated a grievance form and provided staff education, but did not report the abuse allegation to the SA as required. The Nursing Home Administrator later verified that this allegation should have been reported.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for two residents. In the first case, a resident with multiple diagnoses including dementia, Huntington's disease, and repeated falls, experienced a witnessed fall. The facility determined that abuse had occurred based on a progress note from an LPN. However, the investigation was incomplete as it did not include statements from the involved CNA or LPN. Additionally, the staff education provided after the incident was inaccurate, as it did not reflect the resident's care plan requirements for transfer assistance, and only a fraction of employees signed the education documentation. In the second case, another resident with intact cognition and a history of falls and other medical conditions reported that a CNA was abusive, describing being manhandled and treated rudely during care. The grievance was documented, but the investigation did not follow facility policy, as it lacked immediate action, root cause analysis, interviews with other potentially affected residents, and witness statements from involved staff. There was also no documentation of staff education signatures or further investigative records related to this allegation. Both incidents demonstrate that the facility did not adhere to its own policies regarding the immediate and thorough investigation of abuse allegations. Required investigative steps, such as obtaining statements from all involved parties and ensuring accurate staff education, were not completed, resulting in deficiencies in the facility's response to reported abuse.
Failure to Administer Medications Timely per Physician Orders
Penalty
Summary
A deficiency was identified when a resident's medications were not administered in accordance with physician orders and facility policy. The facility's policy requires medications to be administered within one hour of the prescribed time unless otherwise specified. Record review and staff interviews revealed that a resident, who had diagnoses including osteomyelitis, epilepsy, peripheral vascular disease, depression, and osteoarthritis, experienced multiple late administrations of both morning and evening medications. The resident, who was cognitively intact and their own decision maker, reported to the surveyor that their medications, including antiepileptic drugs, were late most days and specifically had not been received by the expected time on the day of the survey. Review of the Medication Administration Record (MAR) showed that the resident's scheduled 8:00 AM medications were administered late on at least seven occasions, with administration times ranging from 9:10 AM to 10:06 AM. Additionally, an evening medication scheduled for 8:00 PM was administered at 11:04 PM on one occasion. Staff interviews confirmed that the nurse was running late with the medication pass and that the resident had expressed concerns about the timeliness of medication administration. The Nursing Home Administrator also acknowledged the facility's policy regarding the one-hour window for medication administration.
Failure to Consistently Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to consistently implement fall prevention interventions for a resident assessed as high risk for falls. The resident had a history of repeated falls, cognitive impairment, muscle weakness, and required substantial assistance with mobility and activities of daily living. The care plan included interventions such as fifteen-minute safety checks while sleeping and grip strips on the floor near the bed, but these were not reliably carried out. Specifically, safety checks were not completed for over three hours on one occasion, during which the resident experienced an unwitnessed fall resulting in head lacerations. Additionally, grip strips were not present at the bedside during observations, and staff confirmed these were not placed after the resident changed rooms. Staff interviews revealed inconsistent implementation and documentation of the prescribed interventions. The DON and ADON acknowledged that grip strips were not installed in the new room and that 15-minute safety checks were not always performed or properly documented. The ADON also indicated that the checks were not consistently listed as care plan interventions and that CNAs did not always follow the intended protocols. Observations further showed the resident was at risk while seated in a Broda chair, with poor posture and sliding down, requiring staff assistance. The facility's own policy required staff to identify and implement interventions based on the resident's specific risks and to monitor and adjust these interventions as needed. Despite the resident's high fall risk and documented history of falls, the facility did not ensure that the care plan interventions were consistently in place or that staff adhered to the established protocols, leading to preventable lapses in supervision and safety.
Failure to Ensure Qualified Infection Preventionist and Adequate Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was responsible for the infection prevention and control program, as required by CMS regulations. After the previous IP left unexpectedly, the facility assigned IP duties to IP-C and the DON, but neither had completed the required specialized training in infection prevention and control. IP-C had started the CDC IP training modules but had only completed 10 out of 24 modules, while the DON had not begun any IP training. The newly hired IP had just started training and was not yet qualified. The facility also lacked an infection prevention and control policy that described the IP's training requirements or specified the number of hours needed for the IP role. Surveyor interviews and record reviews revealed that, during this period, there were multiple instances where staff returned to work before meeting CDC recommendations following COVID-19 or gastrointestinal illness. Additionally, the facility assessment did not specify the required hours for the IP position, and there were gaps in the infection prevention process due to the absence of a trained IP. The facility did not have a trained IP available to train the new IP, further contributing to deficiencies in the infection prevention and control program.
Medication Labeling, Dating, and Storage Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to ensure medications and biologicals were properly labeled, dated, and stored according to professional standards and facility policy. During observations, multiple instances were noted where medications, including inhalers, insulin, eye drops, and supplements, lacked open dates or were left unlabeled. For example, an LPN confirmed that a Med Pass 2.0 supplement on the medication cart was not dated when opened, and an RN acknowledged leaving medication unattended on top of a medication cart in the hallway. Additionally, several residents' medications, such as inhalers and insulin, were found without required open dates, despite pharmacy labels specifying expiration periods after opening. Further inspection of medication storage areas revealed the presence of expired and undated medications and medical supplies. Surveyors found numerous expired items, including vacutainer devices, lubricating jelly packets, blood tubes, syringes, and skin repair cream, as well as undated and open medication packages for several residents. Staff interviews confirmed that these items were expired and should have been removed from storage. The facility's policies require that expired or discontinued medications be returned or destroyed and that all medication storage compartments remain locked and not left unattended. Additional deficiencies were observed on medication carts, where open, unlabeled, and undated medications and supplies were found, including inhalers, nasal sprays, eye drops, and other treatments. Staff interviews with LPNs and the DON confirmed that medications such as eye drops, inhalers, and nebulizer packets should be dated when opened and that expired items should be disposed of. Despite the facility's stated practice of conducting audits and checking dates before use, these lapses in medication management were directly observed during the survey.
Failure to Implement and Enforce Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and staff interviews. Several staff members did not use appropriate personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions (EBP), including during transfers, hygiene, and wound care for a resident with chronic diabetic wounds. The resident's room initially lacked EBP signage, and staff were observed assisting the resident without PPE, despite the facility's policy requiring gloves and gowns for high-contact care activities. Additionally, staff knelt on the floor during wound care without using a barrier, contrary to infection control protocols. Another resident on EBP for an ankle infection did not receive care in accordance with PPE requirements. A registered nurse assessed the resident's foot without gloves or a gown and later stated that PPE was only necessary for toileting, not for wound assessment, indicating a lack of understanding of EBP protocols. Furthermore, staff failed to sanitize blood pressure equipment and a stethoscope after use on a resident, and the nurse acknowledged that the equipment should have been sanitized but did not do so. The facility also did not adhere to CDC and Wisconsin Department of Health Services guidelines regarding staff return-to-work criteria following COVID-19 or gastrointestinal illness. Staff with COVID-19 or GI symptoms returned to work earlier than recommended, and the facility's documentation did not consistently record the date of last symptoms, making it difficult to verify compliance. The infection line lists and time clock records provided did not include necessary information to ensure staff met the required exclusion periods before returning to work.
Failure to Submit PASRR Level II Screens After 30-Day Hospital Exemption Expired
Penalty
Summary
The facility failed to ensure that a Pre-admission Screening and Resident Review (PASRR) Level I Screen was followed by a Level II Screen when the 30-day hospital exemption expired for two residents. Both residents were identified as suspected of having a serious mental illness on their PASRR Level I Screens and were granted a 30-day hospital exemption. However, after the expiration of the exemption, there was no evidence in the medical records that a PASRR Level II Screen was submitted for either resident. One resident had a diagnosis of anxiety disorder and was prescribed Ativan, with a Brief Interview for Mental Status (BIMS) score indicating no cognitive impairment. The other resident had diagnoses of insomnia, depression, and anxiety disorder, was prescribed multiple psychotropic medications, and had a BIMS score indicating moderate cognitive impairment. The Admissions Coordinator confirmed responsibility for completing PASRRs and acknowledged that the required Level II Screens were not submitted after the exemptions expired.
Failure to Ensure Ongoing Dialysis Communication and Fistula Monitoring
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis center and did not consistently monitor the fistula site for a resident who required hemodialysis. The resident, who had diagnoses including dementia, anxiety, end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic neuropathy, received dialysis three times weekly. Facility policy required daily monitoring of the fistula or graft for pulse, buzzing, or thrill, and regular checks for patency. However, the resident's care plan and Medication Administration Record did not reflect daily monitoring for bruit/thrill, and only eight dialysis communication entries were documented over an eight-month period. Staff interviews confirmed that monitoring for bruit/thrill was not included in the resident's MAR or TAR, and there was confusion among staff regarding what information was sent to and received from the dialysis center. The Director of Nursing and other staff indicated that the facility's policy and physician's orders should be followed, but the required aftercare instructions and consistent communication with the dialysis center were lacking. The dialysis center also reported not receiving the expected documentation from the facility, and there was no communication binder in place for the resident.
Medication Administration Error: Wrong Laxative Given
Penalty
Summary
A deficiency occurred when a registered nurse administered the wrong medication to a resident during the morning medication pass. Specifically, the nurse gave Senna-Plus, which contains both sennosides and docusate sodium, instead of the prescribed Senna 8.6 mg, as documented in the resident's Medication Administration Record (MAR) for constipation. The facility's policy requires medications to be administered according to prescriber orders and for staff to verify the correct medication, dosage, and resident before administration. The error was observed by a surveyor and later confirmed through record review and staff interview, with the Director of Nursing acknowledging that medications should be given as ordered.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, resulting in the inappropriate use of antibiotics for three residents. For one resident with a history of abdominal wall abscess, anemia, endometrial cancer, MRSA infection, and fibromyalgia, the medical record showed that the resident did not meet McGeer's criteria for a urinary tract infection (UTI) based on culture results, yet antibiotic therapy was administered. The physician was not notified that the criteria for infection were not met. Similarly, another resident with a duodenal malignancy, bacterial infection, and a stage 2 sacral pressure ulcer received antibiotics for a skin and soft tissue infection (SSTI) despite only meeting two of the four required new or increasing signs or symptoms per McGeer's criteria. This resident was also omitted from the infection line list, and the physician was not updated regarding the lack of infection criteria. A third resident, with diagnoses including head injury, COPD, and atherosclerotic heart disease, was prescribed antibiotics for a respiratory tract infection (RTI) without documentation of any signs or symptoms meeting McGeer's criteria. The infection documentation only noted a sinus infection without further detail, and the physician was not informed that the resident did not meet the criteria for infection. In all three cases, the facility did not follow its own policy requiring communication of lab results and clinical status to the prescriber to determine the appropriateness of antibiotic therapy.
Failure to Update Care Plans for Hoyer Sling Use
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for three residents, specifically regarding the practice of leaving Hoyer slings underneath them while seated in Geri chairs and wheelchairs. The facility's policy, dated July 2017, mandates the removal of slings after using a mechanical lift, but this was not adhered to for residents R11, R5, and R3. The surveyor's observations and staff interviews confirmed that the slings were routinely left under residents, contrary to the facility's policy. Resident R11, who has Alzheimer's disease, a history of amputation, and is at high risk for skin breakdown, was observed with a Hoyer sling left under them in a Geri chair. Despite having a care plan for skin integrity issues, the care plan did not include interventions related to the sling. Similarly, Resident R5, who is severely cognitively impaired and at moderate risk for skin breakdown, was observed with a sling left under them in a recliner. R5's care plan also lacked updates regarding the sling. Both residents reported no discomfort from the sling, but the practice was inconsistent with the facility's policy. Resident R3, who is not cognitively impaired and has a history of hemiplegia and diabetes, was observed with a sling left under them after being transferred to a recliner. R3's care plan did include an intervention to leave the sling underneath, but R3 reported discomfort and requested a blanket for additional comfort. Interviews with CNAs and the Director of Nursing revealed that the practice of leaving slings under residents was common, despite the facility's policy requiring their removal. The Nursing Home Administrator mentioned a recent inservice suggesting the practice was acceptable, but no supporting documentation was provided.
Inadequate Use of Assistive Devices Leads to Resident Left Hanging in Lift
Penalty
Summary
The facility failed to ensure the adequate use of assistive devices to prevent injury for a resident, identified as R3, who experienced issues with the lift battery dying mid-transfer. R3, who was not cognitively impaired and required assistance due to conditions such as hemiplegia, hemiparesis, and an acquired absence of the right leg, reported being left hanging in the lift while staff replaced the battery. This situation occurred because the lift battery often died during transfers, and staff had to leave the room to retrieve a new battery. R3 had communicated with maintenance staff about the battery issues, and the facility had ordered new batteries. Interviews with staff revealed that the lift battery dying mid-transfer was a known issue, and staff did not consistently check the battery life before use. The Maintenance Director and Nursing Home Administrator confirmed that new batteries had been ordered and that there were chargers and extra batteries available, although only one battery was observed in the charger during the survey. The Nursing Home Administrator stated that staff should use the manual release to lower residents if a battery dies mid-transfer, but this procedure was not followed, resulting in the resident being left suspended in the lift.
Improper Catheter Bag Placement for Two Residents
Penalty
Summary
The facility failed to provide appropriate care and services for two residents with indwelling catheters, as observed by surveyors. On the specified date, the catheter drainage bags of two residents were found in contact with the floor, contrary to the facility's urinary catheter policy, which aims to prevent urinary-associated complications, including infections. The first resident, who had a history of fractures and hypertension and moderate cognitive impairment, was observed with their catheter bag on the floor due to the bed being in the lowest position. A Certified Nursing Assistant confirmed the improper placement of the catheter bag. The second resident, with a history of hemiplegia, hemiparesis, anemia, and gross hematuria, and severely impaired cognition, was observed with their catheter bag dragging on the floor while attached to their wheelchair. A Licensed Practical Nurse verified the improper placement and adjusted the bag. The Director of Nursing also confirmed that catheter bags should not touch the floor, indicating a lapse in adherence to the facility's infection control procedures.
Inconsistent Adherence to Prescribed Diet for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a prescribed diet was consistently followed for a resident with type 2 diabetes, who was on a consistent carbohydrate hydro-oligomeric (CCHO) diet. During a survey, it was observed that the resident received a full piece of cake instead of the prescribed half piece, as indicated on their meal ticket. The resident accepted the larger portion, stating they were okay with it for that day. The dietary staff, including a cook and a dietary aide, acknowledged the discrepancy and mentioned that they often provided residents with their preferred portion sizes, even if it deviated from the prescribed diet. The dietary manager confirmed that the resident should have received a half piece of cake according to their CCHO diet. However, the facility lacked a policy regarding adherence to prescribed diets, relying instead on staff to follow diet cards. This lack of a formal policy contributed to the inconsistency in following the resident's dietary requirements, as staff prioritized resident preferences over the prescribed diet orders.
Infection Control Deficiency Due to Lack of PPE and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of staff during the care of a resident on Enhanced Barrier Precautions (EBP). On January 9, 2025, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) provided wound care and assisted with the transfer of a resident without wearing the required personal protective equipment (PPE). The resident, who had multiple diagnoses including severe sepsis, open wounds, and a history of stem cell and bone marrow transplants, was on EBP due to the risk of infection. Despite the presence of an EBP sign on the resident's door, the LPN and CNA did not adhere to the facility's policy requiring PPE during high-contact care activities. Additionally, the facility's policy on cleaning and disinfection of resident-care items was not followed. After assisting the resident, the CNA exited the room with a vital signs machine and placed it in the hallway without disinfecting it, contrary to the facility's policy that requires reusable items to be cleaned and disinfected between residents. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that staff should have worn PPE during high-contact care and that durable medical equipment should be sanitized between each resident use.
Failure to Timely Report and Investigate Resident Altercation
Penalty
Summary
The facility failed to ensure a thorough investigation of an abuse allegation involving two residents. The incident involved a resident with intact cognition and another resident with severe cognitive impairment. The altercation occurred when one resident reportedly yelled and rammed their wheelchair into the other resident in the activity room. Although staff were aware of the incident, it was not reported to the administration in a timely manner, leading to a delay in reporting the incident to the State Agency beyond the required 24-hour timeframe. The facility's investigation revealed that staff were aware of the incident on a Friday evening, but the administration was not informed until the following Monday. The investigation could not determine which staff member intervened during the incident. Additionally, there was no proof of education for certain staff members who were on duty during the incident, indicating a lapse in ensuring all staff were trained on reporting requirements. This deficiency highlights a failure in internal reporting processes and staff education regarding abuse allegations.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility did not ensure garbage and refuse were properly disposed of in outside garbage receptacles. During an initial kitchen tour, the surveyor and the Dietary Manager (DM) observed three outside refuse dumpsters with open lids and garbage on the ground. Specifically, a bag of garbage was found behind the middle dumpster, and scattered pieces of paper were observed around all three dumpsters. The DM indicated that the lids were likely open for ease of use but acknowledged they should be shut to prevent rodents. The DM identified the garbage as belonging to Certified Nursing Staff (CNA) but did not take immediate action to remove it.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not allowing six residents to make choices regarding their meals. For instance, Resident 1, who had moderate cognitive impairment and specific dietary needs, was not asked what they wanted to eat and was given an inadequate protein equivalent. The meal provided did not match the dietary instructions on the meal ticket, and the resident expressed that staff did not ask them about their meal preferences. Resident 4, who had a pureed diet and was non-verbal, was not offered the double portions of entrees as indicated in their plan of care. Instead, they received items not listed on the menu or meal ticket, and staff did not verify if the resident's daughter could make dietary choices on their behalf. Similarly, Resident 10, who also had a pureed diet, did not receive the double portions or the correct items listed on their meal ticket. Staff assumed the resident's preferences without asking. Other residents, including Residents 25, 27, and 39, also did not receive meals according to their dietary plans and preferences. Staff made assumptions about their meal choices without consulting them or their activated power of attorney for healthcare. The facility's dietary manager admitted that they did not consider asking residents about their meal preferences, and the regional manager acknowledged that residents' choices were not being honored. The facility planned to implement a new system to address this issue, but at the time of the survey, the deficiency was evident.
Failure to Provide Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide timely written notifications of transfer to three residents (R204, R36, and R19) and did not notify the State Long-Term Care Ombudsman of these transfers. Specifically, R204 was transferred to the hospital due to low blood sugar levels, R36 was transferred twice due to acute kidney injury and low blood pressure with associated symptoms, and R19 was transferred twice due to right-sided weakness and a fall with a head injury. In each case, the medical records did not indicate that the residents received written transfer notices or that the Ombudsman was notified of the transfers. The Assistant Nursing Home Administrator confirmed that written transfer notices were not provided to the residents, and the facility's records showed that the Ombudsman was not notified of the transfers. The Nursing Home Administrator indicated that nurses are expected to use the facility's transfer form when a resident is transferred to the hospital, but this procedure was not followed. The facility's documentation policy, revised in December 2016, requires that details of the transfer or discharge be documented in the medical record and communicated to the receiving healthcare provider, including providing appropriate notices to the resident and/or legal representative.
Failure to Provide Bed Hold Policy Information
Penalty
Summary
The facility did not ensure that three residents received written information regarding the duration of the facility's bed hold policy, the reserve bed payment policy, and the right to return to the facility when they were transferred to the hospital. Resident 204 was transferred to the hospital due to a low blood glucose reading and did not receive a copy of the bed hold policy. This was confirmed by the Assistant Nursing Home Administrator. Similarly, Resident 36 was transferred to the hospital twice, once for acute kidney injury and once for low blood pressure, headache, and dizziness, but did not receive the bed hold policy on either occasion. The Assistant Nursing Home Administrator confirmed that the bed hold policy was not provided for these transfers, despite a nursing note being completed. Resident 19 was transferred to the hospital twice, once due to right-sided weakness and once due to a fall with a head injury, and did not receive a copy of the bed hold policy on either occasion. The Assistant Nursing Home Administrator confirmed that the bed hold policy was not provided for these transfers. The Nursing Home Administrator indicated that it is expected for nurses to provide a copy of the facility's bed hold policy and transfer form when a resident is transferred to the hospital. However, this expectation was not met in these cases, leading to the deficiency.
Failure to Ensure Resident Safety and Proper Fall Management
Penalty
Summary
The facility did not ensure each resident received adequate supervision and assistive devices, did not complete fall assessments, and did not implement interventions to prevent falls for two residents. On one occasion, staff used a lift with defective brakes and a defective sling to transfer a resident. Despite repeated warnings from a CNA about the broken sling, it continued to be used. Additionally, the lift with broken brakes was used because the other lift was in use, and management was not aware of the issue until the surveyor's observation. Another resident experienced a fall with a head injury, and the facility failed to appropriately assess the resident following the fall. The resident's care plan was not updated with new interventions to prevent future falls. Despite the IDT's review, the care plan remained unchanged, and the interventions were not accessible to CNAs. Neurochecks were not completed as required, and the documentation was inconsistent with the facility's policies. The facility's policies on safety, supervision, and fall risk management were not followed. The use of defective equipment and the lack of proper assessment and documentation contributed to the deficiencies. The facility's failure to update care plans and ensure staff access to new interventions further exacerbated the issue, leading to inadequate care and supervision for the residents involved.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility did not ensure that a resident received the necessary care and services for respiratory therapy. The resident was provided with CPAP therapy without a physician's order, and the need for and use of CPAP therapy was not included in the care plan for assessment, evaluation, or monitoring. The facility's CPAP Therapy policy requires a physician's order and documentation of various aspects of the therapy, which were not followed in this case. Additionally, the facility's Respiratory Therapy-Prevention of Infection policy outlines specific procedures for preventing infection, which were also not adhered to, as evidenced by the lack of labeling on the CPAP machine's tubing to indicate when it was last changed. The resident, who had diagnoses including obstructive sleep apnea, dementia, weakness, and anxiety, was observed with a CPAP machine on the bedside table. The resident indicated that not all staff were educated on the CPAP mask/machine, leading to inconsistent use. The Director of Nursing confirmed that the resident did not have a physician's order for CPAP therapy and that the care plan did not address the use of CPAP therapy or the cleaning schedule for the equipment. The tubing on the CPAP machine was also not labeled with a date/time, which is necessary for infection prevention.
Failure to Monitor High-Risk Medication
Penalty
Summary
The facility did not ensure proper monitoring of a high-risk medication for one resident diagnosed with diabetes mellitus. The resident had physician orders for both short-acting and long-acting insulin to manage high blood sugar levels. However, the resident's plan of care lacked interventions to monitor for signs and symptoms of hypoglycemia and hyperglycemia. This deficiency was identified during a review of the resident's medical record and confirmed through an interview with the Director of Nursing (DON). The resident's medical record included specific orders for Humalog and Lantus insulin, with detailed instructions on dosage and administration. Despite these orders, the resident's baseline care plan did not address the need to monitor for potential complications related to blood sugar levels. The DON acknowledged that the comprehensive care plan was incomplete and that the baseline care plan did not include necessary monitoring interventions for hypoglycemia and hyperglycemia.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 70 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Green Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodside Lutheran Home | 3 mi | ★★★★★ | 13 | 0 |
| Grancare Nursing Center | 3.1 mi | ★★★★★ | 6 | 0 |
| Green Bay Health Services | 3.3 mi | ★★★★★ | 0 | 0 |
| Ccc Of West Green Bay | 3.5 mi | — | 0 | 0 |
| Edenbrook Of Green Bay | 4.4 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.