Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pleasant View Nursing Home during CMS and state inspections, most recent first.
A resident’s APOA signed a consent form requesting an influenza vaccination in accordance with facility policy, which requires consent prior to vaccine administration and placement of the consent in the medical record. However, review of the resident’s electronic health record showed no documentation that the flu vaccine was administered, refused, or that education was provided. During interviews, the DON confirmed that only the consent could be found and acknowledged that the expectation would be that the vaccine was administered when a signed consent is present.
A resident over age 65 on hospice care, with severe dementia, HTN, atherosclerotic heart disease, and supraventricular tachycardia, had prior COVID-19 vaccinations and had POA consent documented for both COVID-19 and influenza vaccines. The resident received the influenza vaccine, but there was no record that the 2025–2026 COVID-19 vaccine was administered or declined, despite facility policy requiring education, offering, and documentation of COVID-19 vaccination for eligible residents. During interview, the DON confirmed there was no documentation of administration or refusal of the COVID-19 vaccine for this resident.
A resident with COPD, pneumonia, cancer, and significant mobility needs was found unresponsive and pulseless on the floor of his room, but CPR was not started immediately. An RN left to get the LPN and check the resident’s code status in the computer before compressions began, while staff interviews showed confusion about emergency equipment, lack of code drill experience, and no reliable system to ensure a CPR-certified staff member was always on duty.
The facility did not complete annual performance evaluations for five CNAs within the required 12-month timeframe. All evaluations were conducted on the same day during the survey, and the DON confirmed that these were completed after surveyors arrived, in violation of facility policy.
A staff member witnessed a resident being slapped and verbally threatened by a family member, but the incident was not immediately reported to the administrator or designee as required. Instead, the staff member left a written statement under a supervisor's door, resulting in a delay in reporting. Facility policy on immediate abuse reporting was not followed, and there was no documented verification that staff received required abuse reporting education.
Two residents with severe cognitive impairment and dementia were subjected to involuntary seclusion by staff. In one case, a CNA blocked a fire door with a mechanical lift to restrict a resident's movement, and in another, a RA confined a resident to her room and shut the door after an episode of agitation. Both actions were contrary to facility policy and resulted in the residents being separated from others against their will.
A resident with severe cognitive impairment and a history of aggressive behavior was involved in multiple incidents of physical aggression towards other residents. Despite the facility's policy to prevent abuse, interventions were inconsistent and insufficient, leading to repeated altercations. The care plan did not adequately address known triggers or provide effective interventions to prevent further incidents.
A resident with cognitive impairment struck another resident with a walker, but the incident was not reported to the state agency as required. Despite staff witnessing and documenting the event, it was not reported due to a misunderstanding of reporting requirements, as staff believed the absence of pain or injury negated the need for reporting.
A facility failed to thoroughly investigate an incident of potential resident-to-resident abuse. A resident with severe cognitive impairment struck another resident with a fist after a mobility issue. Although immediate interventions were implemented, the investigation lacked additional staff interviews, witness statements, and assessments of other residents' safety perceptions, violating the facility's policy on abuse investigations.
The facility failed to ensure medication availability for two residents, leading to missed doses. One resident with chronic obstructive pulmonary disease missed doses of Combivent due to unavailability, while another resident missed doses of Famotidine, Prednisone, and Sertraline. Agency nurses lacked access to the Omnicell system, contributing to the deficiency.
Three residents with severe cognitive impairments were involuntarily secluded behind a wall in a facility, isolating them from other residents and activities. The wall was erected to prevent wandering, but families were not informed, leading to distress. Staff believed it provided safety, but families were shocked by the lack of interaction and stimulation.
The facility failed to maintain a sanitary environment for food preparation and dishwashing, affecting all 64 residents. The kitchen floor was unclean, and the dishwashing machine did not reach the required rinse temperature. Logs for sanitizer testing and dishwasher temperatures were incomplete. Staff shortages and maintenance issues contributed to these deficiencies.
Three residents were moved within the facility without being given the opportunity to refuse the transfer, despite the facility's policy allowing for such refusal. The residents, all severely cognitively impaired, were moved to a different unit without their families being adequately informed of their right to refuse. The facility justified the moves as necessary due to staff supervision gaps, but failed to communicate this right to the families verbally.
A resident's bathroom was observed to be soiled with stool over several days, despite the facility's claim of daily cleaning. The resident's family reported having to clean the room themselves due to the facility's inaction. Housekeeping staff were unaware of the need for cleaning, and the NHA stated the bathroom had been cleaned.
The facility failed to notify the Ombudsman and provide complete discharge notices for two residents with Alzheimer's, omitting transfer locations and appeal rights. Families were shocked and unaware of their right to appeal.
The facility failed to provide an ongoing program of activities for three residents on the Way Unit, as required by their care plans. Despite having severe cognitive impairments and specific activity preferences, these residents were not documented as participating in or being offered activities. Interviews with staff revealed confusion about responsibility for activities, and no documentation was available to show activities were offered or declined.
The facility failed to provide sufficient qualified nursing staff on the Way Unit, leaving Resident Assistants (RAs) without Certified Nursing Assistants (CNAs) to care for residents requiring increased supervision. RAs, who were not CNAs, worked alone and were unable to perform hands-on care or manage emergencies effectively. The Nursing Home Administrator confirmed the lack of CNAs and reliance on a phone system for assistance, which was inadequate. This staffing issue compromised resident safety and well-being.
The facility failed to provide adequate supervision and safety, leading to multiple incidents involving residents. A resident fell during an improper transfer, another was transported unsafely in a wheelchair, and several residents with aggressive tendencies were left unsupervised, resulting in altercations. Staff did not consistently follow care plans and facility policies, contributing to these deficiencies.
The facility failed to follow care protocols for two residents. One resident did not receive required neurological checks after a fall, and another resident was not weighed daily as ordered, with the physician not consistently informed of significant weight changes. Interviews revealed inconsistencies in the facility's process for obtaining and documenting weights.
A resident with hemiplegia received care from a CNA and DON who failed to follow proper hand hygiene and infection control practices. The CNA did not wash hands upon entering the room, used the same gloves for multiple tasks, and did not disinfect surfaces after use. The DON did not notice these lapses during the care. The facility's hand hygiene policy was not followed, resulting in deficiencies.
A long-term care facility failed to provide adequate supervision and safety measures, leading to a resident with Alzheimer's disease eloping through an alarmed door and being found at the bottom of a stairwell. The facility also did not effectively manage wandering behaviors, as several residents reported uninvited entries into their rooms by other residents. Additionally, a resident's leg was injured due to improper wheelchair use. These incidents highlight deficiencies in the facility's supervision and safety protocols.
The facility failed to maintain an effective infection prevention and control program, affecting all residents. Staff returned to work too soon after GI symptoms, contrary to CDC guidelines. Additionally, a resident was observed accessing the ice machine with bare hands, violating infection control protocols.
Several residents reported grievances about a wandering resident entering their rooms and taking belongings, but the facility failed to follow its grievance process. Staff were aware of the concerns but did not report them to management or document the incidents, leading to unresolved grievances and a lack of accountability.
A facility failed to store and label medications properly, leading to the administration of expired medications to residents. A nurse administered expired Betaxolol eye drops to a resident with glaucoma, and expired acetaminophen was given to two residents for chronic pain. Additionally, an opened Tubersol vial with an unreadable date was found, indicating lapses in checking expiration dates.
A resident with moderate cognitive impairment expressed concerns about staff not consistently making her bed and failing to provide meal substitutions as requested. Despite the facility's policy, the resident waited 40 minutes for a replacement muffin, which was only provided after surveyor intervention. This affected the resident's quality of life and nutritional intake.
A resident was observed with medications on the floor and an empty medication cup, indicating a failure to ensure safe self-administration. The facility's policy requires a physician's order for self-administration, which the resident did not have. An LPN left medications in the resident's room without verifying the order, and the resident reported taking the pills after picking them up from the floor. Interviews with staff confirmed that this practice was unsafe and not in line with facility policies.
A facility failed to conduct a comprehensive sleep assessment before prescribing Lemborexant, a hypnotic medication, to a resident with insomnia. Despite the resident's history of sleep issues, the care plan lacked specific interventions for sleep monitoring, and no sleep tracking was documented. The facility's policy requires a comprehensive review before prescribing psychotropic medications, which was not followed in this case.
A resident was not offered the PCV20 pneumococcal vaccine as recommended by the CDC, despite the facility's policy requiring assessment and offering of the vaccine upon admission. The resident's medical record lacked documentation of education on the vaccine's benefits and side effects, as well as consent or declination. The infection preventionist confirmed the oversight, leading to incomplete pneumococcal vaccinations for the resident.
Lack of Documentation and Administration of Influenza Vaccination After Consent
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was offered and received an influenza vaccination, and that the resident’s medical record contained documentation of administration, refusal, or education regarding the vaccine. The facility had a written Influenza Vaccination policy dated 7/1/25 stating that individuals receiving the influenza vaccine, or their legal representative, must provide consent prior to administration and that the consent would be located in the resident’s medical record. For one resident (R4), the Activated Power of Attorney (APOA) signed the facility’s Influenza Vaccination Information and Release Form on 10/2/25, indicating that they had read information about influenza and the flu vaccine, understood the benefits and risks, and requested that the influenza vaccine be given to the resident named on the form. Despite the signed consent, surveyor review of R4’s electronic health record revealed no documentation that the influenza vaccination was administered, nor any record of refusal or education. During an interview on 3/23/26, the DON stated that they had located the consent but were still looking for documentation that the vaccine had been given. On 3/24/26, the DON reported they were unable to find any documentation indicating that R4 had received the influenza vaccination. When asked if the expectation would be that the vaccine was administered when a signed consent was present, the DON confirmed that this was the expectation.
Failure to Administer or Document 2025–2026 COVID-19 Vaccination for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that when COVID-19 vaccine was available, each resident was offered and either administered or documented as declining the 2025–2026 COVID-19 vaccine, in accordance with facility policy and CDC/FDA guidance. The facility’s COVID-19 Vaccination policy, implemented 11/10/25, states that residents and staff are to be educated and offered the COVID-19 vaccine, and that vaccinations will be offered when supplies are available unless medically contraindicated, already administered during the time period, or refused. For adults 65 years and older who were previously vaccinated, the policy references a schedule requiring administration of two doses of the 2025–2026 vaccine. One resident, R3, over the age of 65 with severe unspecified dementia with agitation, primary hypertension, atherosclerotic heart disease, and supraventricular tachycardia, was admitted on hospice with an activated POA. R3 had prior COVID-19 vaccinations in 2021 and 2023. A progress note dated 9/29/25 documented that the resident’s daughter/POA agreed to both COVID-19 and influenza vaccines, and that hospice would be contacted for approval. The resident subsequently received the influenza vaccine on 10/27/25, but there was no documentation that the 2025–2026 COVID-19 vaccine was administered or declined. During an interview on 3/24/26, the DON stated she was unable to find any information indicating that the COVID-19 vaccine had been given to or refused by this resident and stated she would have expected the resident to receive the vaccine after verbal consent from the POA, confirming the lack of documentation and follow-through on the COVID-19 vaccination for R3.
Delay in CPR and emergency response for a full code resident
Penalty
Summary
The facility failed to provide immediate basic life support, including CPR, to a full code resident who was found unresponsive on the floor of his room. The resident had diagnoses including pneumonia due to Pseudomonas, COPD, weakness, hypertension, prostate cancer, and anemia. His most recent MDS indicated a BIMS of 13, showing he was cognitively intact, and he required substantial to maximum assistance for mobility and transfers. His advance directives stated that he wanted CPR if found unresponsive, pulseless, and not breathing. On the morning of the event, an RN found the resident face down on the floor next to his bed, with a laceration on his forehead and a bluish color to his face. The RN did not immediately initiate CPR. Instead, the RN left the room to get the LPN supervisor and checked the resident’s code status on the computer while the resident remained down. The LPN then checked for a pulse, confirmed none, and started compressions after the code status was verified. CNA testimony indicated that several minutes elapsed between the resident being found and compressions beginning. The record also showed that the facility did not ensure staff were competent in code response equipment and did not ensure a CPR-certified staff member was always in the building. Staff interviews reflected uncertainty about where emergency supplies were kept, lack of knowledge about the contents of the emergency bag, and lack of code drill experience. The LPN stated she did not know where the ambu bag was located and had no knowledge of what was in the emergency bag. The RN and other staff described that code status was in the computer, but the RN still left the room before CPR began. Survey findings also documented that the facility’s emergency oxygen setup and code response equipment were not consistently understood by staff.
Failure to Complete Timely Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for all Certified Nursing Assistants (CNAs) within the required 12-month period, as mandated by facility policy. Specifically, five CNAs did not have their annual performance evaluations completed on time. For each CNA reviewed, the most recent annual evaluation was not conducted until after the 12-month period had elapsed. The evaluations for all five CNAs were completed on the same day, which coincided with the surveyor's visit. During the survey, the Director of Nursing (DON) confirmed that the evaluations were completed after the surveyors arrived at the facility. The DON also acknowledged that annual performance evaluations are required every 12 months, as per facility policy. The surveyor's review of records and interviews with the DON confirmed that the evaluations had not been performed in a timely manner prior to the survey.
Failure to Timely Report Alleged Abuse to Proper Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse were reported to the appropriate authorities in accordance with state law and facility policy. Specifically, a staff member witnessed an incident in which a resident's wife yelled at and slapped the resident, then grabbed his face and made a threatening statement. The staff member wrote a statement about the incident approximately one hour after witnessing it and left it under a supervisor's door, as instructed by her supervisor. However, the supervisor was not present for four days, resulting in a delay in reporting the incident to the administrator or designee. Interviews and record reviews revealed that the facility's procedures for immediate reporting were not followed. The facility policy requires that all allegations of abuse be reported immediately, but not later than two hours after the allegation is made, to the administrator and other required agencies. The staff member did not directly notify the administrator, DON, or social services supervisor, and the education provided to staff regarding abuse reporting was not documented or verified for completion, particularly among agency staff. This lapse led to a failure in timely reporting and documentation as required by both facility policy and state regulations.
Failure to Prevent Involuntary Seclusion of Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents from involuntary seclusion, as evidenced by two separate incidents involving residents with severe cognitive impairment and a history of dementia and agitation. In the first case, a resident identified as an elopement risk and known to wander was found to have been intentionally restricted from accessing certain areas. An agency Certified Nursing Assistant (CNA) closed one side of a fire door and blocked the other side with a mechanical lift, effectively confining the resident to a specific area to prevent entry into other residents' rooms. This action was observed by the Maintenance Assistant, who immediately reported the obstruction. In the second incident, another resident with Alzheimer's disease and a history of physical aggression was subjected to involuntary seclusion by a Resident Assistant (RA). The RA was observed by two staff members taking the resident to her room and shutting the door after the resident became agitated and physically aggressive. The resident was heard yelling for help, and another CNA intervened to assist her. Prior to the incident, the resident had been sitting quietly at the nurses' station, and the RA's actions were attributed to anger over the resident's earlier behaviors. Both residents involved were severely cognitively impaired, ambulatory, and wore wander guard alarms. The facility's own policies defined involuntary seclusion as separating a resident from others or confining them to their room against their will, except in short-term, monitored, therapeutic situations. In both cases, staff actions did not align with these guidelines, resulting in the residents being involuntarily secluded.
Failure to Prevent Resident-to-Resident Aggression
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving a resident with significant cognitive impairment and a history of aggressive behavior. This resident, diagnosed with Alzheimer's disease, anxiety disorder, and severe dementia with agitation, was involved in three separate incidents of physical aggression towards other residents. Despite the facility's policy to prevent abuse and neglect, the interventions in place were inconsistent and insufficient to prevent these occurrences. In the first incident, the resident struck another resident on the shoulder while trying to navigate through a crowded area. The staff member present witnessed the event but was unable to intervene in time to prevent the physical contact. The second incident involved the same resident striking another resident in the arm when unable to maneuver around a wheelchair in the hallway. This incident was witnessed by staff, but it was not reported to the state agency or investigated as abuse due to the perceived lack of willful intent. The third incident occurred when the resident struck another resident on the shoulder, prompting immediate separation and one-to-one supervision. Despite these repeated incidents, the facility's care plan for the aggressive resident did not adequately address the known triggers or provide effective interventions to prevent further altercations. The facility's failure to update the care plan and implement consistent interventions resulted in ongoing resident-to-resident aggression.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the state survey agency within the required timeframe. The incident involved two residents, one of whom, R3, with significant cognitive impairment, struck another resident, R11, with a walker. Despite the incident being witnessed by staff and documented, it was not reported to the state agency or investigated as required by the facility's policy. R3, who has Alzheimer's disease and other cognitive impairments, was observed striking R11, who also has significant cognitive impairment, with a walker. The incident occurred when R3 was unable to maneuver around R11's wheelchair. Although the incident was documented and the physician and family were informed, it was not reported to the state agency. Staff interviews revealed a misunderstanding of the reporting requirements, with some staff believing that the absence of pain or injury negated the need for reporting. The facility's policy mandates immediate reporting of abuse allegations, but this was not adhered to in this case. Interviews with the Administrator and Social Services Director indicated a lack of clarity regarding what constitutes reportable abuse, particularly in cases involving residents with cognitive impairments. Despite staff training on abuse reporting, the incident was not reported due to a perceived lack of injury or willful intent, highlighting a gap in the facility's compliance with reporting protocols.
Incomplete Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an incident of potential resident-to-resident abuse involving two residents. One resident, with severe cognitive impairment and a history of behaviors such as pacing and combativeness, struck another resident with a fist after being unable to maneuver her walker around the other resident's wheelchair. The incident was documented, and immediate interventions were put in place, such as assigning one-on-one staff supervision to the aggressive resident. However, the investigation was incomplete as it lacked additional staff interviews, witness statements from other residents or visitors, and did not assess whether other residents felt safe. The facility's policy on abuse, neglect, and exploitation requires a comprehensive investigation when such incidents occur, including identifying and interviewing all involved parties and documenting the investigation thoroughly. Despite this policy, the investigation into the incident was insufficient. Interviews with staff revealed that while they were aware of the reporting process, the investigation did not include follow-up interviews or statements from other potential witnesses, nor did it assess the safety perceptions of other residents. This lack of thorough investigation into the resident-to-resident abuse incident constitutes a deficiency in the facility's handling of the situation.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure the availability of medications for two residents, R6 and R9, leading to missed doses. R6, who was admitted with chronic obstructive pulmonary disease and other conditions, had an order for Combivent Respimat Inhalation Aerosol Solution to be administered four times daily. However, the medication was not available on multiple occasions, resulting in missed doses on several days. Documentation in the electronic medical record (EMR) indicated that the inhaler was not found or not available, and there were delays in reordering and receiving the medication from the pharmacy. Similarly, R9, admitted with diagnoses including essential hypertension and anxiety, had orders for Famotidine, Prednisone, and Sertraline. These medications were not administered on several occasions due to unavailability, despite being stocked in the facility's Omnicell system. Progress notes indicated that the medications were on order or waiting for delivery, but there was a lack of access to the Omnicell system by agency nurses, which contributed to the delay in medication administration. Interviews with staff revealed that agency nurses were not given access to the Omnicell system, which contained the necessary medications. This lack of access, combined with issues in the medication ordering process through the EMR, led to the deficiency. The Director of Nursing confirmed that the facility had an Omnicell system and that regular nurses had access, but agency nurses did not, which contributed to the residents missing their medications.
Involuntary Seclusion of Residents Behind Erected Wall
Penalty
Summary
The facility failed to ensure that three residents were free from involuntary seclusion, as they were moved from their original unit to a different unit within the facility and placed behind a wall. This wall was erected to keep the residents from wandering off the unit, effectively isolating them from other residents and activities. The families of these residents were not informed about the wall or the isolation, leading to distress and confusion among family members when they discovered the situation. The residents involved had severe cognitive impairments and various diagnoses, including Alzheimer's Disease, dementia, and other related conditions. Their care plans indicated a need for social interaction and activities, which were not provided in the secluded area. The facility's actions were reportedly taken to manage resident-to-resident incidents and wandering behaviors, but the method of isolation was not communicated transparently to the families. Interviews with staff and family members revealed a lack of awareness and understanding of the situation. Some staff members believed the wall provided a safer environment for the residents, while family members expressed shock and concern over the lack of interaction and stimulation for their loved ones. The facility's decision to erect the wall was made by the interdisciplinary team, but it was not adequately communicated to or agreed upon by the residents' families.
Deficiencies in Kitchen Sanitation and Dishwashing Procedures
Penalty
Summary
The facility was found to have deficiencies in maintaining a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 64 residents. Observations revealed that the kitchen floor was unclean, with visible dirt and food debris, and the tile flooring near the drain had cracks and gouges. The facility's policy requires regular cleaning of kitchen and dining areas, but interviews with dietary aides indicated that the floors were not being cleaned adequately, and the kitchen was only mopped and swept on specific days. The dietary aide also mentioned a shortage of staff, which contributed to the lack of cleanliness. The dishwashing machine was not reaching the required rinse temperature of 180 degrees Fahrenheit, as evidenced by the temperature logs. The logs showed multiple instances where the final rinse temperature was below the required level, and corrective actions were taken by running the dishes twice. Interviews with dietary aides and maintenance staff revealed that the dish machine had been experiencing issues for about two weeks, and the maintenance team was aware of the problem. The facility's policy mandates that dishwashing machines using hot water for sanitization must maintain specific temperatures, and any inadequacies should be reported and corrected immediately. The facility's logs for sanitizer testing and dishwasher temperatures were incomplete, with several entries left blank. The nursing home administrator acknowledged that the dish machine was not functioning correctly and that the logs were incomplete. Maintenance staff indicated that a boiler issue was preventing the water from reaching the necessary temperature for proper dish sanitization. The dietary manager confirmed that the floors were not being cleaned as required and that a new staff member was being trained for deep cleaning tasks. Overall, the facility failed to adhere to its policies for maintaining a sanitary environment and ensuring proper dish sanitization.
Failure to Uphold Residents' Right to Refuse Room Transfers
Penalty
Summary
The facility failed to uphold the residents' right to refuse room transfers, as evidenced by the cases of three residents who were moved without being afforded the opportunity to refuse the transfer. The facility's policy on room changes, revised in March 2021, states that residents have the right to refuse room changes unless the move is necessary for specific reasons, such as relocating between skilled and non-skilled nursing units or for staff convenience. However, in the cases of the three residents, the facility initiated room transfers without adequately informing the residents' representatives of their right to refuse. Resident 1, who is severely cognitively impaired with a BIMS score of 0, was moved to a different unit without the family being given a clear explanation or the right to refuse the transfer. The family was contacted late on a Friday and was told to sign paperwork by Monday, with the move occurring early that morning. Similarly, Resident 2, also severely cognitively impaired, was moved without the family being informed of their right to refuse. The family was contacted while on vacation and was told the move was to prevent incidents, but they were not given the option to refuse the transfer. Resident 3, who also has severe cognitive impairment, was moved under similar circumstances. The facility's social worker stated that the right to refuse was included in the paperwork, but the families reported not being informed of this right. The Nursing Home Administrator justified the moves as necessary due to staff supervision gaps and stated that the right to refuse was written on the form, but the families were not adequately informed verbally. This lack of communication and failure to uphold residents' rights constitutes a deficiency in the facility's handling of room transfers.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, identified as R2, as evidenced by the condition of R2's bathroom. On multiple occasions, a surveyor observed that R2's toilet was soiled with stool, and this condition persisted over several days. R2's family member reported that the bathroom had been in this state for several days and that they had to clean the room themselves due to the facility's inaction. Housekeeping staff, when interviewed, stated that rooms are usually cleaned daily but were unaware of the specific need to clean R2's bathroom. The Nursing Home Administrator claimed that the bathroom had been cleaned, despite evidence to the contrary.
Failure to Notify Ombudsman and Provide Complete Discharge Notices
Penalty
Summary
The facility failed to properly notify the Office of the State Long-Term Care Ombudsman of two facility-initiated discharges and did not ensure that the written notices contained all necessary information. The notices for two residents, who were both severely cognitively impaired with Alzheimer's Disease, did not include the location to which the residents were to be transferred or discharged, a statement of the residents' appeal rights, or the contact information for the entity that handles such appeals. Despite the facility's claim that the notices were sent to the Ombudsman, the Ombudsman reported not receiving them. The first resident, who had a history of behavioral symptoms and was dependent on assistance for daily activities, was given a 30-day discharge notice due to the facility's inability to safely care for her. The notice lacked specific details about the transfer location and appeal rights. The resident's family was shocked by the decision and expressed concerns about the impact of the move on the resident's quality of life. The facility's social worker and nursing home administrator both stated that the decision was made because the resident no longer required skilled nursing care, but the family was not informed about their right to appeal the decision. The second resident, also severely cognitively impaired, was issued a similar 30-day discharge notice. The notice was missing critical information, including the transfer location and appeal rights. The resident's family was upset and surprised by the facility's decision, which was attributed to the resident's involvement in incidents with other residents. The facility's staff claimed that the resident would be better served in a dementia-specific placement, but the family was not made aware of their right to appeal the discharge. The Ombudsman confirmed that they did not receive the required notices for either resident.
Failure to Provide Activities for Residents on Way Unit
Penalty
Summary
The facility failed to provide an ongoing program to support resident choice of activities based on comprehensive assessments and care plans for three residents residing on the Way Unit. The activity staff and other staff working on the Way Unit did not provide or offer activities to these residents, and there was no documentation of their participation or being offered activities since their relocation to the unit. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyor. Resident 1, who has severe cognitive impairment and various diagnoses including Alzheimer's Disease and depression, was not documented as having participated in or declined activities. The resident's care plan indicated a preference for simple, structured activities and required staff assistance for participation. Similarly, Resident 2, also severely cognitively impaired, had no documentation of activity participation or declination. This resident's care plan emphasized engagement in simple activities and required assistance with decision-making. Resident 3, with advanced Alzheimer's and other mental health conditions, was noted to have limited participation in activities, with staff attempting new approaches without documented success. Interviews with activity staff and CNAs revealed a lack of clarity and responsibility regarding the provision and documentation of activities for these residents. Activity staff were unaware of any activities being conducted on the Way Unit, and CNAs were uncertain about their role in facilitating activities. The Nursing Home Administrator and Business Office Manager were unable to provide documentation of activities being offered or declined by the residents, highlighting a systemic issue in the facility's activity program management.
Insufficient Qualified Nursing Staff on Way Unit
Penalty
Summary
The facility failed to ensure sufficient, qualified nursing staff were available at all times to meet the needs of residents, specifically for three residents who required increased supervision. Resident Assistants (RAs), who were not Certified Nursing Assistants (CNAs), were left to work alone on the Way Unit, which housed these residents. The facility's staffing schedule showed multiple instances where RAs worked without a CNA present, despite the residents' need for increased supervision and care. Interviews with staff and family members confirmed that RAs were working alone and were not equipped to provide hands-on care, as they lacked the necessary certification and training. The Nursing Home Administrator acknowledged that the RAs were not CNAs and could not perform physical care, relying instead on a phone system to call for assistance from another unit. However, there were instances where calls for help went unanswered, leaving the RAs unable to manage emergencies effectively. The RAs expressed concerns about the safety of the residents and their ability to provide adequate supervision, especially when all residents were awake and required line-of-sight monitoring. The facility's failure to assign a CNA to the Way Unit compromised the safety and well-being of the residents, as the RAs were not trained in dementia care or managing behaviors, and the unit was understaffed.
Inadequate Supervision and Safety Measures in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for several residents, leading to multiple incidents. One resident, who required a two-person transfer with a full body lift, was transferred independently by a staff member, resulting in a fall. Another resident was transported without foot pedals on their wheelchair, causing their leg to drag under the seat, and was transferred to the toilet without the use of a gait belt as per their care plan. Additionally, a resident was observed self-transferring without appropriate footwear, and another was transferred using an incorrect sling size, which was not suitable for their weight. The facility also failed to provide adequate supervision for residents with a history of aggressive behavior related to dementia. Several residents were observed in common areas or activities without staff within line of sight, despite care plans indicating the need for monitoring due to potential aggression. This lack of supervision led to multiple resident-to-resident altercations, including incidents where residents hit or grabbed each other, resulting in physical confrontations. The facility's policies and care plans were not consistently followed by staff, contributing to the deficiencies. Staff failed to adhere to protocols for using mechanical lifts, transferring residents, and monitoring those with aggressive tendencies. These lapses in following established procedures and care plans resulted in unsafe conditions and increased the risk of accidents and resident-to-resident incidents.
Failure to Follow Care Protocols for Neurological Checks and Weight Monitoring
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards and the comprehensive person-centered care plan for two residents. Resident 8, who has severe cognitive impairment and is dependent on staff for transfers, experienced an unwitnessed fall. According to the facility's protocol, neurological checks should have been conducted at specific intervals following the fall. However, the checks were not completed as required, with significant gaps in the monitoring schedule, and the facility did not adhere to its protocol. Resident 4, who has diagnoses including congestive heart failure and chronic pain, was admitted with orders to be weighed daily and to notify the physician of any significant weight changes. The facility failed to obtain daily weights as ordered, and the physician was not consistently informed of weight changes that exceeded the specified parameters. The documentation shows multiple instances where weights were not recorded, and the facility did not follow the physician's orders for daily monitoring. Interviews with the Director of Nursing and staff revealed inconsistencies in the process of obtaining and documenting weights. The facility's standard practice was not followed, and there was a lack of communication regarding resident refusals and significant weight changes. The failure to adhere to the care plan and physician's orders resulted in deficiencies in the care provided to both residents.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices were followed, as observed during the care of a resident with hemiplegia secondary to a cerebrovascular accident. The resident, who is dependent on staff for care and transfers, was receiving personal care from a CNA and the Director of Nursing (DON). The CNA did not perform hand hygiene upon entering the resident's room and proceeded to apply gloves and perform peri care without washing hands. After completing the peri care, the CNA did not remove gloves or perform hand hygiene before continuing to use the same gloves to handle clean washcloths and rinse the resident. The CNA further compromised infection control by placing dirty washcloths in the clean wash basin and on the bedside table, and by not disinfecting these surfaces or the mechanical lift after use. The CNA continued to use the same soiled gloves to apply barrier cream to the resident and to brush the resident's hair, failing to perform hand hygiene at any point during these tasks. The DON, who was present during the care, did not notice the missed hand hygiene opportunities or the improper handling of washcloths and did not intervene. Upon interview, the CNA acknowledged the failure to perform hand hygiene and disinfect surfaces, while the DON admitted to not realizing the lapses in infection control practices during the care. The facility's policy on hand hygiene, which emphasizes its importance in preventing the spread of infections, was not adhered to, leading to the observed deficiencies in infection control practices.
Inadequate Supervision and Safety Measures in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents, particularly for a resident with a history of elopement and exit-seeking behaviors. This resident, who has Alzheimer's disease and moderate cognitive impairment, was able to exit through an alarmed door and was found at the bottom of a stairwell. The door alarm had sounded for 15 seconds, but staff did not respond promptly due to a malfunctioning alert board and lack of staff presence in the immediate area. This incident led to a finding of Immediate Jeopardy. Additionally, several residents expressed concerns about wandering residents entering their rooms uninvited. One resident, who is not cognitively intact, was not provided with any protective measures such as a stop sign to prevent another resident from entering her room. Staff were aware of these concerns but did not implement effective interventions to address them. The facility's failure to adequately supervise and manage wandering behaviors contributed to the ongoing issues. Furthermore, the facility did not ensure proper use of equipment, as evidenced by a resident whose leg got caught under a wheelchair due to the absence of foot pedals. The facility's policies on falls and wandering were not effectively implemented, as staff failed to document and monitor interventions adequately. These deficiencies highlight the facility's inability to maintain a safe environment for its residents.
Removal Plan
- Staff in nursing, life enrichment, housekeeping, and maintenance were educated regarding the intervention to have line of sight supervision when resident indicates that he is exit-seeking and the need to call maintenance immediately if there are issues identified with the Wander Guard or call light system.
- All resident care plans were reviewed for individuals with identified wandering/elopement concerns. All elopement assessments are up to date as are all of the assessments for new residents that would have put them into this category.
- The interventions were reviewed for adequacy to meet safety needs and to determine if all increased supervision needs were being met. No other care plans were identified where increased supervision was listed as an intervention.
- The policy for managing care plan interventions regarding wandering and exit-seeking was changed to include monthly reviews of all plans, or sooner if elopement occurs, by the clinical team which includes DON, nursing management, and social services.
- Daily audits of the delayed egress door system functionality were implemented.
- The procedure for notifying maintenance regarding the failure of the elopement prevention system has been updated to include notification immediately to prevent elopement.
- Education was provided on the facility's elopement prevention program listing the names and pictures of the individuals who are high risk for elopement on each unit. Staff have been educated/reeducated on the program and their roles.
- DON or DON designee will audit the care plan interventions for proper practice and implementation on a daily basis for one week, then weekly for a month, then monthly for three months, then quarterly.
- Action and reeducation will take place promptly upon discovery if it is discovered that interventions are not being properly employed.
- Maintenance supervisor will review the WorxHub system for work orders regarding the elopement prevention system that are not being reported promptly on a daily basis for one week, then weekly for one month, and monthly for three months, then quarterly. Action and education will take place promptly if policy is not followed.
- Results will be presented to QAPI.
Inadequate Infection Control and Staff Return-to-Work Practices
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, which has the potential to affect all 69 residents. The deficiency was identified through interviews and record reviews, revealing that staff returned to work too soon after experiencing gastrointestinal (GI) symptoms. The facility's policy on communicable diseases states that personnel with active infections should not be in contact with residents or their environments until they are no longer contagious. However, the infection preventionist (IP) was found to be using incorrect criteria for determining return-to-work dates, allowing staff to return on the last symptom date instead of adhering to CDC guidelines, which recommend a 48 to 72-hour symptom-free period before returning to work. Additionally, the facility's surveillance for infections policy requires ongoing monitoring of healthcare-associated infections and adherence to infection prevention practices. Despite this, the facility's staff line lists from March to June 2024 showed multiple instances where staff with GI symptoms returned to work on the last symptom date, contrary to CDC guidelines. The infection preventionist admitted to completing the well dates incorrectly and acknowledged the need for a new process to ensure compliance with the guidelines. Furthermore, surveyors observed a resident, identified as R24, reaching into the kitchenette's ice machine with bare hands, which is against the facility's infection control practices. This incident was corroborated by a group interview and direct observation by surveyors. The unit manager confirmed that the resident should not have been accessing the ice bin in such a manner, indicating a lapse in monitoring and enforcing infection control protocols within the facility.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances for several residents, as evidenced by interviews and record reviews. Residents R31, R39, R10, R40, R2, R6, R50, and R59 voiced concerns about a wandering resident, R24, who frequently entered their rooms uninvited and took personal belongings. Despite these grievances being reported to staff, there was no follow-up or documentation of the incidents, and the facility's grievance process was not followed. Staff members, including CNAs and LPNs, were aware of these concerns but did not report them to the Grievance Official or management. The facility's policy on grievance handling, revised in 2017, mandates that grievances be promptly addressed and resolved to the satisfaction of the resident. However, the policy was not adhered to, as evidenced by the lack of documentation and follow-up on the grievances reported by the residents. The residents expressed their concerns during a Resident Council Meeting and individual interviews, highlighting the facility's failure to address the issues raised. The Director of Nursing refused to be interviewed, and the Nursing Home Administrator acknowledged that staff should follow the grievance process but did not ensure compliance. Specific examples include R31 and R10 reporting that R24 entered their rooms and took belongings, with no action taken by staff. R2 was visibly upset and reported feeling unsafe due to R24's behavior, yet her concerns were not addressed. R59 also reported similar issues with another resident, R56, and was told by a staff member to "just put up with it." These incidents demonstrate a systemic failure in the facility's grievance handling process, resulting in unresolved grievances and a lack of accountability among staff.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored and labeled according to standard practices, leading to the administration of expired medications to residents. During a medication pass, a surveyor observed a registered nurse administering expired Betaxolol eye drops to a resident diagnosed with primary open-angle glaucoma. The nurse acknowledged the medication was expired and should not have been administered. This incident highlights a lapse in the facility's adherence to its policy, which requires checking expiration dates before administering medications. Additionally, the surveyor found expired acetaminophen tablets in the medication cart on the 300 wing, which had been administered to two residents for chronic pain. The registered nurse responsible for administering the medication confirmed that the expired acetaminophen was given to the residents and recognized it as a medication error. The nurse contacted the provider and informed the residents about the error, noting that no adverse effects were observed. The surveyor also discovered an opened multidose vial of Tubersol in the medication room refrigerator with an unreadable date, making it impossible to determine if it was expired. The Director of Nursing acknowledged the issue and the inability to verify the expiration date. The facility's policy requires staff to check medication expiration dates regularly, but the surveyor's findings indicate a failure to consistently follow this protocol, resulting in the administration of expired medications.
Failure to Honor Resident's Choices in Meal and Environment
Penalty
Summary
The facility failed to honor a resident's choices regarding meal substitutions and maintaining a tidy environment, impacting the resident's quality of life. The resident, who is moderately cognitively impaired and requires assistance with activities of daily living, expressed dissatisfaction with the staff's inconsistency in making her bed. Despite her requests, the bed was often left unmade, which was particularly distressing for her when she had visitors. The resident values her personal belongings and a tidy environment, but staff did not consistently respect these preferences. Additionally, the resident's meal preferences were not honored. During a meal, the resident requested a substitution for a blueberry muffin, which was removed from her tray without a replacement being provided. Despite the facility's policy allowing for meal substitutions, the staff failed to offer an alternative in a timely manner. The resident waited 40 minutes for a replacement, which was only provided after the surveyor's intervention. This incident highlights the staff's failure to respect and fulfill the resident's meal choices, affecting her nutritional intake.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was clinically appropriate to self-administer medications. The resident, identified as R30, was observed with medications on the floor and an empty medication cup on the bedside table. The facility's policy requires that residents may only self-administer medications if deemed appropriate by the attending physician and interdisciplinary care planning team. However, R30 did not have a physician's order to self-administer medications, and the facility's assessment did not evaluate R30's ability to take oral medications safely. Despite this, medications were left in R30's room by an LPN, who did not verify if R30 had a self-administration order. Interviews with the LPN, Unit Manager, and Director of Nursing revealed that the medications should not have been left in R30's room without a physician's order. The LPN admitted to leaving the medications in the room and not checking back on R30, who reported taking the pills after picking them up from the floor. Both the Unit Manager and Director of Nursing confirmed that leaving medications in the room and allowing a resident to take medications off the floor was not safe practice. The incident highlights a failure to adhere to the facility's policies and procedures regarding medication administration and resident safety.
Inadequate Sleep Assessment for Hypnotic Medication Use
Penalty
Summary
The facility failed to ensure adequate indications for the use of a high-risk medication, Lemborexant, prescribed to a resident for insomnia. The resident, who has a history of hemiplegia, type 2 diabetes, bipolar disorder, visual hallucinations, major depressive disorder, generalized anxiety disorder, and insomnia, was admitted with a cognitive status indicating they were intact. Despite previous assessments indicating sleep issues, the facility did not conduct a comprehensive sleep assessment before prescribing the hypnotic medication. The facility's policy requires a comprehensive review of the resident's signs and symptoms to identify underlying causes before prescribing psychotropic medications, which was not adhered to in this case. The resident's care plan lacked specific interventions for sleep monitoring and non-pharmacological approaches, and there was no documentation of sleep tracking in the Medication Administration Record or Treatment Administration Record. The facility provided a general monthly evaluation document with minimal sleep assessment, which was insufficient to justify the use of the hypnotic medication. The Director of Nursing was unavailable for an interview regarding this concern, and the facility did not provide any additional sleep-specific assessments when requested by the surveyor.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R40, was offered the pneumococcal vaccine in accordance with CDC recommendations. The facility's policy requires that residents be assessed for eligibility to receive the pneumococcal vaccine series upon admission and that they be offered the vaccine unless medically contraindicated or previously vaccinated. However, R40, who had a documented history of receiving pneumococcal vaccines, was not offered the PCV20 vaccine as recommended. There was no documentation of a declination or consent for the pneumococcal vaccine in R40's medical record. The deficiency was identified during a survey when it was found that the facility did not provide education to the resident or the resident's representative regarding the benefits and potential side effects of the pneumococcal vaccine. Additionally, the facility failed to document whether the resident received the vaccine or refused it. The infection preventionist confirmed that R40 should have been offered the PCV20 vaccine, but this did not occur, resulting in incomplete pneumococcal vaccinations for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 131 citations issued within 25 miles in the last 12 months — including the 5 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 Monroe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monroe Health Services | 0.9 mi | ★★★★★ | 9 | 0 |
| New Glarus Home | 15.3 mi | ★★★★★ | 18 | 1 |
| Serenity Estates Of Lena | 18.3 mi | ★★★★★ | 3 | 0 |
| Medina Nursing Center | 19.5 mi | ★★★★★ | 8 | 1 |
| Evansville Manor Nursing And Rehab, Llc | 21 mi | ★★★★★ | 29 | 3 |
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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.