Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sheridan Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to notify resident representatives of hospital transfers. Two residents were sent to the ER/hospital for changes in condition, including altered mental status, hypoglycemia, and a fall with head impact, but the facility had no evidence that the POAHC or listed representative was informed. Staff stated they did not call when a resident was "their own person," despite the facility policy requiring notification of significant changes and transfers.
Unclean Resident Room Environment: A resident’s room had repeated observations of food crumbs, paper, tape, a treatment bottle, straw papers, dust, dirt, and other debris under and around the bed and dresser. The same conditions were seen across multiple observations, and the resident stated that a clean room was important and that he liked a clean room.
Failure to thoroughly investigate an allegation of resident harassment. One resident reported that another resident was watching them while they slept and making unwelcome sexual comments. Although both residents were cognitively intact, the facility obtained only one RN statement and did not include other staff interviews or witness statements, despite policy requiring interviews of all involved persons and others with knowledge of the allegation.
A facility failed to include comprehensive, person-centered care plan interventions for three residents. Two residents had documented trauma histories, including physical assault and abuse, but their care plans did not reflect those histories or include trauma-specific interventions. Two residents were also documented as being in an intimate relationship, yet their care plans did not address that psychosocial need with person-centered interventions. The SW confirmed these issues should have been included in the comprehensive care plans.
Failure to document and provide scheduled showers for a cognitively intact resident who required partial/moderate assistance with bathing and transfers. Family reported the resident complained about not getting showers, and review of shower sheets showed blank entries with no indication the resident received a shower or refused. CNA and UM described a process for tracking showers and refusals, but documentation was missing for the identified dates.
A resident with a pressure injury had delayed and incorrectly transcribed wound orders, gaps in TAR documentation, and no care plan revision when the wound reopened despite ongoing risk for skin breakdown. Another resident’s admission wound assessment was incomplete, with no full description or staging of a coccyx wound present on admission until the wound had worsened and was later assessed as an unstageable sacral wound. Staff interviews confirmed the admission assessment and wound documentation were not completed as required.
A resident with a history of alcohol use, opioid abuse, anxiety, and depression had care plan interventions for substance use concerns, but the resident later became unresponsive in the dining room, required Narcan, and was sent to the ER for suspected overdose. The hospital summary documented the resident had ingested pain meds, had been pocketing pills, and may have taken more than prescribed. Facility staff gave conflicting accounts of the cause, were unaware of key hospital findings, and no formal investigation was documented.
A facility failed to provide medically-related social services for two cognitively intact residents who were in an intimate relationship. Staff, including the SW, RCC, UM, and DA, were aware the residents were holding hands, spending private time together, and using the conference room for privacy, but neither resident had a completed Intimacy and Sexual History assessment or an intimate relationship care plan with person-centered interventions.
A resident with type 1 diabetes had ordered basal insulin and sliding-scale insulin, but MAR review showed repeated blood sugar entries marked as NA or left blank and two missed scheduled Lantus doses. The DON stated the documentation was not acceptable and that if it was not documented, it was not done, while the LPN said she checked the blood sugar, clicked not applicable, and did not enter progress notes.
Failure to Notify Physician of Abnormal Lab Results: A resident with hyperkalemia and CKD stage 4 had abnormal BMP/CMP results showing elevated K+, BUN, creatinine, and low CO2, calcium, and GFR. The record did not show that the MD was notified of the abnormal lab results, and staff gave inconsistent accounts of who handled lab notifications.
A resident on EBP for a wound received care without consistent PPE use and hand hygiene. CNAs provided bathing, incontinence care, and transfers while wearing gloves but not gowns, and an LPN did not disinfect the overbed table before placing wound supplies, did not perform hand hygiene after wound care glove removal, and left the room without hand hygiene after removing PPE. The resident had functional quadriplegia, was cognitively intact, had an indwelling catheter, and had a Stage 3 pressure injury.
RN Coverage Not Maintained for Required 8 Consecutive Hours: Survey review found that an RN was not scheduled for 8 consecutive hours on a Sunday, leaving the facility without the required RN coverage. The scheduler stated an RN had called in for the night shift and the on-call staff filled the shift with an LPN without confirming that another RN covered the required hours or that an RN had worked earlier shifts.
Inaccurate PBJ Staffing Submission: The facility did not ensure accurate PBJ staffing data were submitted to CMS for Quarter 4. Surveyor review of weekend schedules and nurse postings showed LPNs, RNs, and CNAs present on each shift and unit, with call-ins/no-shows and staff covering open shifts, yet CMS reported excessively low weekend staffing and a one-star staffing rating. HR-G stated corporate submits the PBJ data and could not explain why the facility was flagged for low weekend staffing.
Incomplete infection surveillance records showed the facility did not maintain a functioning infection prevention and control program. The IP stated the former DON handled surveillance during the missing months, but logs and summary data were unavailable, and later-submitted monthly logs still lacked required details such as onset dates, criteria met, cultures, treatment, precautions, and resolution information for multiple residents. The DON also reported that September graphs were not completed and were mislabeled with 2024 instead of 2025.
A surveyor found that the North unit medication refrigerator lacked a temperature log, despite facility policy requiring daily temperature documentation to keep refrigerated meds within the proper range. The surveyor also observed an unopened insulin vial for a resident stored in a drawer in the med room instead of the refrigerator; the DON confirmed it should have been refrigerated and moved it.
The facility failed to provide required NOMNC and SNF ABN notices for two residents when Medicare Part A coverage ended. For one resident, the NOMNC was emailed to the guardian without verification of receipt, the initial email went to the wrong address, and no SNF ABN was provided. For another resident, the NOMNC was signed but no SNF ABN was given, and staff acknowledged the omission during interviews.
A resident with intact cognition and no activated POA was sent to the hospital after an unwitnessed fall, but the facility could not locate the required transfer notice or bed hold notice. The DON stated the floor nurse was supposed to complete the notice and the business office manager was to follow up, but neither document was found in the resident’s record.
A resident with vision loss and moderate cognitive impairment reported being blind and needing staff to read her mail, but staff were not doing so. The care plan for impaired visual function contained only a general intervention and did not include person-centered supports specific to the resident’s needs, although staff later described some close-up assistance with TV, crafts, knitting, and optometry follow-up.
A resident at moderate risk for pressure injuries had a care plan requiring heel offloading, but surveyors repeatedly observed both heels directly on the mattress while the resident was in bed. The resident stated heels were rarely offloaded, could not reposition independently, and sometimes had heel pain; the DON agreed the heels should have been offloaded.
Failure to Follow Fall-Risk Transfer Interventions: A resident with hemiplegia/hemiparesis, impaired one-sided extremity function, and a history of a fall was observed self-transferring between the bed and wheelchair despite care plan interventions requiring assistance with transfers and removal of the wheelchair from bedside while in bed. A CNA was unaware of the resident’s fall-risk status and interventions, while an LPN stated the interventions were active and the DON said they may have been intended for another resident.
A resident with pulmonary fibrosis was observed receiving oxygen by nasal cannula at 4.5 L/min without humidification, despite an order for 3 L/min continuous. The facility’s policy required humidification for nasal cannula flow rates above 4 L/min, but the DON was unsure of the resident’s oxygen settings and the LPN Unit Manager later confirmed the oxygen was set too high and not humidified.
Medication Error Rate Exceeded 5 Percent: Surveyors found the facility’s medication error rate was 12 percent, with 3 errors out of 25 opportunities. An RN was observed crushing carvedilol, Eliquis, and amlodipine together, mixing them with water, and administering them combined via a resident’s G-tube instead of giving each medication separately as required by facility policy. The resident only had a standing order to crush meds as appropriate, and no pharmacist consultation or prior order authorizing cocktailing was documented at the time of the observation.
A resident with aphasia, hemiplegia, and hemiparesis had no immunization record in WIR, and the facility did not document that flu or pneumococcal vaccines were offered or refused as required by policy. The DON stated the resident had refused vaccinations, but there was no consent form or documented risk-versus-benefit discussion, and later said the resident wanted the flu vaccine and would receive it that day.
Missing COVID-19 Immunization Documentation: A resident with aphasia, hemiplegia, and hemiparesis had no EMR documentation showing whether the COVID-19 vaccine was offered, received, or declined. The MDS showed the resident had intact memory and independent daily cognitive decision making, and the WIR had no vaccine record. The DON stated the resident refused vaccines, but there was no consent or risk-versus-benefit form documenting the refusal, despite the facility policy requiring documentation of education and vaccine status.
Multiple incidents occurred where residents were subjected to abuse or threats of abuse, including inappropriate touching, verbal threats of sexual assault, physical altercations with racial slurs, and verbal abuse by an agency CNA. These events involved both cognitively impaired and intact residents, as well as staff, and were confirmed by facility staff and documented in misconduct reports.
The facility did not consistently report allegations of abuse, neglect, or theft to the State Agency or law enforcement within required timeframes. In several cases, including verbal abuse and suspected theft involving cognitively intact residents, reports were delayed or not made, and law enforcement was not notified as required by facility policy.
The facility did not complete thorough investigations into multiple abuse allegations, including inappropriate touching between residents, verbal threats of sexual assault, and claims of staff verbal abuse. In each case, the facility failed to promptly investigate or notify law enforcement, despite policy requirements, and delayed action after receiving reports from both residents and external sources.
A resident with multiple chronic conditions was no longer permitted to self-administer medications due to repeated non-compliance, including hoarding and improper dosing. Despite this change, the care plan was not updated to reflect the new status, and staff interviews confirmed the oversight.
A facility failed to inform a resident's family member of care conferences in advance, impacting their ability to participate in care planning. The resident, who was cognitively intact, wanted her family involved, but the family member only received a last-minute call about a conference. The Social Services Director admitted there was no system to track invitations, and the Director of Nursing expected family members to be informed in advance.
A resident with paraplegia and functional limitations in a long-term care facility did not receive necessary nail care, as his care plan did not address this need and staff failed to offer assistance. Despite being cognitively intact, the resident's nails were long and thick, requiring staff intervention. The DON suggested it was the resident's responsibility to request nail care, and the CNA was unsure if the resident had been asked about his needs. Eventually, staff had to soak the resident's nails to trim them.
The facility failed to provide timely pressure ulcer treatments for two residents, leading to a delay in care. One resident did not receive treatment for several days after admission due to delayed implementation of orders. Another resident's wound vac system was not applied promptly, and interim dressings were used without proper orders. The DON confirmed these deficiencies, highlighting issues in timely care and documentation.
A resident with a feeding tube did not receive appropriate care, leading to potential infection risks. The facility failed to label and change enteral feeding and water flush bags, as well as the syringe and container, every 24 hours. The resident's feeding tube insertion site had not been cleaned or the dressing changed as required, and the feeding pump was not regularly cleaned. These deficiencies were confirmed by the Unit Manager and DON.
The facility failed to provide necessary medications for two residents, leading to unmanaged pain and delayed antibiotic treatment. A resident did not receive prescribed pain medication due to reordering failures, while another experienced a 22-hour delay in receiving an IV antibiotic after admission. Staff interviews revealed issues with communication and medication ordering processes, impacting resident care.
A resident reported that meals, especially breakfast, were served lukewarm, despite having good flavor. A test tray confirmed the food temperature was too low for palatability. The Dietary Manager acknowledged complaints and noted issues with meal delivery speed and equipment, despite the holding temperature being adequate.
An LPN in an LTC facility failed to follow infection control protocols by taking a treatment cart into a resident's room during pressure ulcer care and returning unused supplies to the cart, risking cross-contamination. The DON confirmed this practice was a concern and that supplies should have remained in the room.
A resident with hearing loss was not provided with a care plan addressing their refusal to wear hearing aids, leading to communication challenges. Despite staff awareness of the issue, no interventions were documented in the care plan or CNA Kardex. The DON acknowledged the oversight in care planning for the resident's hearing needs.
A resident with a complex medical history was prescribed Ativan on a PRN basis without an end date, contrary to the facility's policy on managing drug regimens. The oversight was identified during a survey, and the DON acknowledged the error.
The facility failed to maintain a medication error rate below 5 percent, affecting two residents. One resident received levothyroxine after breakfast and expired Timolol Maleate eye drops. Another resident was given immediate release Venlafaxine instead of the prescribed extended release form due to unavailability. These errors resulted in a medication error rate of 10.71 percent.
A resident was administered 150 mg of immediate release Venlafaxine instead of the prescribed extended release form due to a lack of the correct medication in the backup supply. An LPN, instructed to use immediate release tablets, gave five 37.5 mg tablets to the resident. The error was identified during a surveyor's observation, and the LPN planned to contact the resident's doctor immediately. The Nursing Home Administrator and DON were informed, but no further explanation was provided.
The facility employed an unqualified Food Service Manager (FSM) for 52 of 53 residents, lacking the required certification and experience. The FSM admitted to not having started the necessary certification course since starting the position, and the Administrator was unaware of this deficiency.
The facility failed to provide written transfer notices to two residents and their representatives during emergent hospital transfers, as required by policy. Despite the policy's clear guidelines, the facility's practice involved only verbal communication and documentation for emergency services, without providing the necessary written notice to the residents or their representatives. This oversight was confirmed through staff interviews, revealing a lack of awareness about the requirement.
The facility failed to follow physician orders for weight monitoring for three residents, leading to potential unrecognized weight changes. Despite having complex medical conditions, weights were not recorded as required. Interviews with staff confirmed the expectation to comply with orders, indicating a lapse in adherence to the facility's weight monitoring policy.
Failure to Notify Resident Representatives of Hospital Transfers
Penalty
Summary
The facility failed to notify residents' representatives of transfers to the hospital for 2 of 6 residents reviewed, including R1 and R5. The facility policy titled Notification of Changes stated that significant changes in condition, including transfer or discharge from the facility, require notification of the resident's physician and representative, if known. Despite this, there was no evidence that R5's activated POAHC was notified when R5 was sent to the emergency room or hospitalized multiple times for amputation site bleeding, altered mental status, and hypoglycemia. When interviewed, the DON stated the facility did not notify the representative because staff believed R5 was her own person and later said the facility was not aware of the POA until paperwork was received from the hospital after discharge. R1, whose annual MDS documented a BIMS score of 15 indicating cognitive intactness, was sent to the emergency room after a fall in which R1 reported hitting their head on the floor. R1's ex-spouse was listed as the representative contact on the face sheet, but the fall investigation contained no documentation that the representative was notified of the transfer. The UM stated nurses should contact the representative when a resident goes to the emergency room, while the DON stated that when a resident is their own person the representative is not notified. When asked, R1 stated that the ex-husband was the person R1 would want notified if hospitalization were needed.
Unclean Resident Room Environment
Penalty
Summary
The facility did not provide a safe, clean, comfortable, and home-like environment for one resident, R7, based on repeated observations of the resident’s room. On 6/16/26, the surveyor observed R7 in bed and noted an accumulation of food crumbs, pieces of paper, and other debris under the bed near the baseboard. The surveyor also observed a roll of tape on the floor near the head of the bed, a treatment bottle and multiple straw papers between the bed and the bedside dresser, and an accumulation of dust, dirt, and other debris under the bedside dresser. The same debris and clutter remained in R7’s room during multiple later observations on 6/16/26 and again on 6/17/26. When the surveyor showed the Nursing Home Administrator the condition of the room, the surveyor identified the food crumbs, paper, tape, treatment bottle, straw papers, and dust and dirt that had been observed repeatedly. The Housekeeping Manager stated the facility uses a 5 to 7 step cleaning process and accompanied the surveyor to the room, where a housekeeper was in the process of sweeping. When asked, R7 stated that having a clean room was important and said, “yes, I like a clean room.”
Failure to Thoroughly Investigate Alleged Resident Harassment
Penalty
Summary
The facility did not ensure that allegations involving potential abuse, neglect, and misappropriation of resident property were thoroughly investigated for two residents. A facility reported incident submitted to the State Agency stated that one resident reported being harassed by another resident, including that the other resident watched the resident while sleeping. The incident report documented that the facility could substantiate that the second resident made unwelcome sexual comments to the first resident. The facility policy and procedure for abuse, neglect, and exploitation required immediate investigation and identification and interviewing of all involved persons, including witnesses and others with knowledge of the allegations. Record review showed that the first resident had diagnoses including acquired absence of the right leg below the knee, type 2 DM, COPD, CKD, lymphedema, anxiety disorder, and depression, and had a BIMS score of 15, indicating cognitive intactness. The second resident had diagnoses including CKD, peripheral vascular disease, type 2 DM, psychoactive substance abuse, anxiety disorder, and depression, and also had a BIMS score of 15. The facility obtained only one staff statement from an RN who observed the first resident crying and reporting the harassment. Surveyor interviews with the SW, DON, and NHA indicated that staff interviews were part of the investigation process and that statements should be obtained from all staff members on shift, but the investigation in this case did not include any other staff statements.
Missing comprehensive care plan interventions for trauma and intimate relationships
Penalty
Summary
The facility did not provide comprehensive care plans for three residents reviewed for care plans because the plans did not include documented histories of trauma or person-centered interventions related to those histories. The facility’s Trauma Informed Care policy stated that triggers which may re-traumatize residents with a history of trauma should be identified and added to the care plan, and that trauma-specific interventions should be evaluated for effectiveness. Social Services policy also stated that the resident’s plan of care would reflect ongoing medically-related social service needs and how they were being addressed. One resident was admitted with diagnoses of anxiety disorder and depression, had a BIMS score of 15, and Social Service Evaluation and Trauma Informed Care assessment documented a history of physical assault and verbal and some physical abuse with husband. Survey review found the resident’s comprehensive care plan did not document the trauma history and did not include person-centered interventions for trauma. The Social Worker confirmed that the resident’s trauma should have been included in the comprehensive care plan with person-centered interventions. A second resident was admitted with diagnoses including psychoactive substance abuse, anxiety disorder, and depression, had a BIMS score of 15, and Social Service Evaluation and Trauma Informed Care assessment documented physical assaults with a belt and unexpected deaths of close family members. The resident’s Intimacy and Sexual History documented an intimate relationship with another resident. Survey review found the care plan did not include the trauma history or person-centered interventions for trauma, and did not document the intimate relationship with person-centered interventions. A third resident with depression and a BIMS score of 14 also had an Intimacy and Sexual History documenting an intimate relationship with another resident, but the comprehensive care plan did not document that relationship or include person-centered interventions.
Failure to Document and Provide Scheduled Showers
Penalty
Summary
The facility did not ensure that one resident maintained the ability to perform ADLs related to grooming and personal hygiene because the resident did not receive documented weekly showers on 1/27/26 and 3/10/26. The resident, R4, had an admission MDS with an ARD of 1/27/26 showing a BIMS score of 15, indicating the resident was cognitively intact, with no behavior concerns noted. R4 was assessed as needing partial/moderate assistance with shower/bath and chair/bed to chair transfer. During interview and record review, family members told the surveyor that R4 had complained about not receiving showers and that they had spoken with a nurse about it, though they could not identify the nurse. The facility’s shower sheets reviewed on 6/17/26 were blank for multiple dates, including 1/27/26 and 3/10/26, and did not show whether R4 received a shower or refused one. CNA-F stated that showers are tracked in a shower binder and refusals are documented, and UM-D stated that if a resident refuses, it is documented on the sheet and in the task record. Despite this, the facility was unable to provide documentation showing that R4 received a shower or refused on those two dates.
Incomplete pressure injury assessment, treatment transcription, and care planning
Penalty
Summary
The facility did not ensure comprehensive assessment and care planning for pressure injuries for two residents. One resident was admitted with a deep tissue injury that was later assessed by the wound physician as a Stage 3 left buttocks pressure injury. The wound physician’s order was not entered into the TAR until 2 days later and was transcribed incorrectly, and the resident’s pressure injury was documented as healed shortly afterward. Despite the resident’s Braden score indicating ongoing risk for pressure injury development, there was no update to the care plan to address impaired skin integrity or to address prevention of recurrence when the wound later reopened. The same resident’s pressure injury reopened, and the wound physician documented the reopened left buttocks wound with updated measurements and granulation tissue. The facility did not revise the pressure injury care plan after the wound reopened, and there was no evidence the care plan was reviewed to determine whether it remained appropriate. The TARs also showed multiple gaps in wound care documentation across April, May, and June, including dates when wound care was blank. Staff interviews indicated the TAR is the source nurses use to know what treatment to complete, and if it is not charted, it is not done. A second resident’s admission assessment did not comprehensively assess wounds present on admission. The resident arrived with a coccyx open area, but the admission head-to-toe evaluation did not include wound characteristics such as color, exudate, odor, pain, tissue type, or staging. The resident’s wound was not comprehensively assessed until 7 days later, when the wound had worsened and was documented by the wound RN as an unstageable sacral wound with slough and moderate serous drainage. The DON stated the admitting nurse was responsible for the comprehensive wound assessment and acknowledged that it was not appropriate that this did not occur.
Failure to Address Resident Substance Use and Overdose
Penalty
Summary
The facility failed to provide behavioral health services to ensure a resident with a history of alcohol use, opioid abuse, anxiety, and depression received the highest practicable mental and psychosocial well-being. The resident’s care plan identified substance use concerns and included interventions such as notifying social services, offering reassurance, contacting the doctor, and providing an AA meeting calendar, but the record showed the resident continued to engage in substance-related behavior and later experienced an overdose event while in the facility. On the morning of the event, the resident was found in the dining room in a wheelchair with flaccid arms, not responding to verbal stimuli, mumbling with eyes closed, and breathing shallowly. Narcan was administered for suspected overdose and 911 was called. When EMTs arrived, the resident became more alert and was transferred to the ER for further evaluation and treatment. The hospital discharge summary documented that the resident had ingested pain medications, had been very somnolent, received intranasal Narcan, and later admitted to pocketing pills and possibly taking a stronger dose than prescribed. After the resident returned, the facility’s documentation and staff interviews showed the overdose was not formally investigated and the hospital information was not fully known or addressed by key staff. The resident’s records also reflected a history of opioid addiction and abuse, but staff gave differing accounts about the cause of the overdose, including Delta 8, while others were unaware of the hospital findings that the resident had hoarded medications. The surveyor noted that the facility had no documented investigation to review, and administration acknowledged that a formal investigation should have been completed.
Failure to Complete Intimacy Assessments and Care Plans for Two Residents in a Relationship
Penalty
Summary
The facility did not ensure medically-related social services were provided to help each resident achieve the highest possible quality of life for 2 of 4 sampled residents, R1 and R11. Both residents were cognitively intact, with BIMS scores of 15 on their annual MDS assessments, and both had diagnoses including anxiety disorder and depression for R1, and anemia, essential hypertension, and hypokalemia for R11. Survey observations and interviews showed that R1 and R11 were in an intimate relationship, were seen holding hands in R1's room and on the patio, and were using the conference room for privacy. Staff members including the RCC, UM, and DA were aware of the relationship, and the SW stated awareness that the residents had been spending more time together and getting closer. The SW also stated that intimacy and sexual history assessments were supposed to be completed on admission and that a care plan would be initiated based on the assessment outcome, but both R1 and R11 did not have completed Intimacy and Sexual History assessments. Survey review found that neither resident had a completed intimate relationship care plan with person-centered interventions. The facility's social services policy stated that the facility would provide medically-related social services to each resident and that the social worker would complete initial and quarterly assessments to identify any need for such services and document them in the medical record.
Incomplete insulin and blood sugar documentation for a resident with type 1 diabetes
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident with type 1 diabetes mellitus and diabetic neuropathy/retinopathy. The resident had physician orders for Lantus 4 units subcutaneously at bedtime and Novolog insulin by sliding scale with meals. Review of the resident’s January through April 2026 MARs showed multiple instances where blood sugar documentation for Novolog was recorded as “NA” or left blank, and there was no code on the MAR explaining “NA.” The record also showed that the resident’s scheduled Lantus dose was not administered on 2/6/26 and 3/18/26. During review of the February 2026 MAR, the surveyor noted that the resident’s scheduled Lantus dose on 2/6/26 was documented with “BS” and chart codes indicated “BS” meant blood sugar no coverage required per scale, even though Lantus was a scheduled insulin and not sliding scale. The surveyor also identified numerous dates in February, March, and April 2026 where Novolog blood sugar entries were documented as “NA” or were blank at ordered monitoring times. These included repeated missing or non-specific blood sugar entries across morning, noon, and evening checks. When interviewed, the DON stated that the documentation was not acceptable and that if it was not documented, it was not done. The DON later stated that every one of the identified dates involved one nurse and that the nurse reported the resident’s blood sugars were always below parameters, that “NA” meant not administered, and that there were no nurses’ notes, including for the missed 3/18/26 Lantus dose. The DON also stated the nurse did not know she had to document the actual blood sugar number. The LPN stated she always checked the resident’s blood sugar, usually clicked on not applicable, and did not enter a progress note; she said the blank entries may have been an oversight.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility did not ensure a resident’s physician was promptly notified of laboratory results that were outside clinical reference ranges. The resident had diagnoses of hyperkalemia and chronic kidney disease stage 4, and a physician order dated 3/3/26 directed BMP testing every 2 weeks related to hypokalemia and sodium levels. A nursing note dated 4/8/26 documented a potassium level of 6.2, that the MD was spoken with, and that a new order for Kayexalate was obtained with a repeat BMP ordered for 4/10/26. On survey review, the resident’s 4/9/26 CMP showed multiple abnormal values, including potassium 5.3, chloride 120, carbon dioxide 14, BUN 67, creatinine 5.34, GFR 11, and calcium 7.2, and the 4/21/26 CMP also showed abnormal values, including potassium 5.8, chloride 121, carbon dioxide 13, BUN 60, creatinine 5.47, GFR 10, and calcium 7.5. The surveyor was unable to locate documentation that the physician was notified of either set of abnormal results. During interviews, staff gave differing descriptions of who was responsible for lab notification, and UM-D stated there was nothing charted regarding the abnormal labs on 4/9/26 and 4/21/26.
Infection Control Lapses During EBP Care and Wound Treatment
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for a resident on enhanced barrier precautions (EBP) for a wound. The resident had diagnoses including functional quadriplegia and schizoaffective disorder, bipolar type, was cognitively intact with a BIMS score of 15, required substantial to maximal assistance for rolling, and was dependent for toileting hygiene and transfers. The resident also had an indwelling urinary catheter, was always incontinent of bowel, and had one Stage 3 pressure injury that was present on admission. During morning care, a CNA provided personal care to the resident while wearing gloves but not a gown, despite the EBP sign posted outside the room. The CNA washed the resident’s face, positioned the resident on the side, removed the incontinence product, and cleaned the resident’s buttocks and pressure injury area without wearing appropriate PPE. Later, an LPN entered the room, placed a gown on, washed hands, and donned gloves, but did not disinfect the overbed table before placing treatment supplies on it. While treating the resident’s left buttock pressure injury, the LPN cleansed the wound, applied skin prep, and dressed the wound, but did not remove gloves and perform hand hygiene after wound cleansing and did not perform hand hygiene after removing gloves. The LPN also reached into a pocket for a marker to date the dressing. During catheter care, the LPN left the room without performing hand hygiene after removing PPE, then returned and completed foley catheter care. Additional observations showed CNAs transferring and providing care to the resident without gowns while the resident remained on EBP, and one CNA stated she believed the precautions were for the resident’s roommate who was in the hospital. The Unit Manager confirmed that PPE signage indicated EBP and stated that hand hygiene should be performed after glove removal and that treatment supplies should be placed on a cleaned overbed table.
RN Coverage Not Maintained for Required 8 Consecutive Hours
Penalty
Summary
The facility did not ensure that a registered nurse (RN) worked at the facility for at least eight consecutive hours a day, seven days a week, on 1 of 30 days reviewed. Surveyor review of the facility staff schedule and nurse posting for December 2025 showed that on 12/14/2025, a Sunday, there was not an RN scheduled for 8 consecutive hours. The deficient practice was identified as having the potential to affect all 56 residents residing at the facility on that date. During interview on 1/7/2026, the scheduler stated that if a call-in occurred during working hours, the scheduler would find a replacement, but if a call-in occurred after hours, on weekends, or on holidays, the on-call person would be responsible for finding coverage. The scheduler later stated that an RN had been scheduled for the night shift on 12/14/2025, but the RN called in and the on-call staff replaced the shift with an LPN without confirming whether another RN replaced the shift or whether an RN had worked previous shifts. The surveyor shared the concern with the NHA and DON, and no further information was provided at the time of the write-up.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility did not ensure that it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to CMS. The deficiency involved Quarter 4 (July 1 - September 30, 2025) of the Payroll Based Journal (PBJ), which was reported as having excessively low weekend staffing and a one-star staffing rating. The CMS Electronic Staffing Data Submission Payroll-Based Journal policy manual states that long-term care facilities must electronically submit complete and accurate direct care staffing information, including agency and contract staff, based on payroll and other verifiable and auditable data, and that staffing and census data must be timely and accurate for each fiscal quarter. Surveyor review of the facility's weekend schedules and nurse postings for Quarter 4 showed licensed nurses and CNAs present on each shift and unit, including call-ins/no-shows and staff who picked up open shifts. The schedules reviewed did not appear to show excessive call-ins/no-shows, and the facility assessment documented staffing ratios that were compared to the Quarter 4 weekend schedules with no discrepancies noted or low weekend staffing as reported to CMS. During interviews, HR-G stated that corporate offices submit the PBJ data and that HR-G sends information to corporate, which handles the submission; HR-G also stated that corporate had not raised concerns with staff. When asked about the Quarter 4 PBJ staffing issue, HR-G stated that after reviewing the schedules with corporate, they were not sure why the facility was flagging for low weekend staffing and could not explain the discrepancy.
Incomplete Infection Surveillance Documentation
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection. During review of the facility’s undated Infection Prevention and Control Program policy, the Infection Preventionist was identified as responsible for oversight of surveillance, documentation of incidents and corrective actions, and reporting findings to the Quality Assessment and Assurance Committee. However, when the surveyor reviewed the facility’s infection surveillance documents for January through December 2025, there were no infection surveillance logs, infection rates, or summary reports available for July 2025, August 2025, and September 2025. The Infection Preventionist stated that the former DON had served in that role during July, August, and September 2025 and that the data for those months were unavailable because of the former DON/IP’s record keeping. Later, the DON provided additional documents by email, but the July 2025 monthly infection surveillance log did not include date of onset, whether criteria were met, whether a culture was performed or resulted, whether precautions were initiated, whether treatment was started, or when infection resolved for 4 of 7 residents listed. The September 2025 monthly infection surveillance log did not include signs and symptoms, whether criteria were met, date of onset, whether a culture was taken, or when infection resolved for 9 of 14 residents listed. The DON also stated that the graphs for September were not completed and that the graphs had 2024 on them even though they were from 2025.
Medication Refrigerator Monitoring and Insulin Storage
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional standards in the medication room on the North unit. During a tour with the DON, the surveyor found that the medication refrigerator did not have a temperature log to document that temperatures were maintained within the facility’s required 36-46 degrees F range, even though the facility policy stated that charts are to be kept on each refrigerator and temperatures recorded daily. The surveyor also observed an unopened insulin vial belonging to R3 stored in a drawer in the medication room instead of in the medication refrigerator. When asked about the storage, the DON stated that R3’s insulin should have been in the refrigerator and then placed it there.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility did not inform residents when Medicare Part A coverage ended and items and services would shift to a payor source for which the resident could be charged, because required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) documents were not properly provided for 2 residents. For one resident, Medicare Part A coverage ran from 9/6/2025 through 9/13/2025, and the Social Service Coordinator documented that the resident’s guardian was issued a NOMNC by email; however, no SNF ABN was provided, the initial NOMNC was sent to the wrong email address, and there was no verification that the guardian received the notice. The surveyor also found that the facility’s later audit and request for a signature occurred after the surveyor had already requested the information. For the second resident, Medicare Part A coverage ran from 9/1/2025 through 9/18/2025, the resident had no activated POA, and there was no documentation in the progress notes that the resident was notified when Medicare services ended. A NOMNC was signed by the resident, but no SNF ABN was provided. During interviews, staff stated Medicaid was pending and acknowledged that the SNF ABN was not given and that this was an error; the Nursing Home Administrator and Business Office Manager agreed the resident should have received the SNF ABN notice.
Missing Transfer and Bed Hold Notice After Hospitalization
Penalty
Summary
The facility did not ensure that one resident, R9, received the required transfer notice and bed hold information when the resident was hospitalized after an unwitnessed fall. R9 was admitted to the facility with intact cognition, had a BIMS score of 14 on the quarterly MDS, did not have an activated POA, and was their own person. After R9 was transported to the hospital for further evaluation and admitted, the surveyor reviewed the medical record and found no evidence of a transfer notice or bed hold notice for the hospitalization. The facility policy titled Bed Hold Notice stated that written information should be provided to the resident and/or representative at the time of transfer, including the duration of the State bed hold policy, the reserve bed payment policy, and the right to return to the facility, and that a signed copy should be kept in the record. During interview, the DON stated the floor nurse was supposed to complete the transfer notice and bed hold, with follow-up by the business office manager, but the facility could not locate either document for R9. The DON also stated nursing did not complete the notice when R9 was sent to the hospital and the business office manager did not follow up to complete it.
Care Plan for Vision Loss Was Not Person-Centered
Penalty
Summary
The facility did not ensure a comprehensive care plan was developed and implemented for a resident with vision loss so the resident could attain the highest practicable physical, mental, and psychosocial well-being. The resident was admitted with diagnoses including vision loss, and the MDS dated 8/18/2025 documented moderate cognitive impairment, moderate vision impairment, inability to see newspaper headlines, ability to identify objects, and no use of glasses. During an interview on 01/05/2026, the resident stated she was blind and needed staff to read her mail, which staff was not doing. Survey review of the care plan for impaired visual function showed a focus area initiated on 2/20/2025, but the listed intervention was general and did not include person-centered interventions specific to the resident’s needs. The surveyor noted no interventions tailored to the resident’s reported need for staff to read mail. A CNA stated the resident had visual deficits and had difficulty watching TV, while an LPN unit manager stated the resident had close-up visual interventions, optometry appointments, and assistance with close-up tasks such as crafts and knitting, but did not use visual aids per physician request. The facility’s Kardex later included an intervention to offer support with tasks such as crafts, reading, and knitting if needed.
Heels Not Offloaded per Care Plan
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was cited after the facility did not ensure a resident at risk for pressure injuries received care consistent with the resident’s plan of care. The resident had diagnoses including rheumatoid arthritis, muscle weakness, fibromyalgia, chronic pain syndrome, and adult failure to thrive, and the facility assessed the resident as moderately at risk for pressure injury development with a Braden score of 14. The resident’s care plan included turning and repositioning every 2-3 hours and floating the heels if the resident could not turn and reposition independently. Surveyors observed the resident in bed on multiple occasions with both heels directly on the mattress and not offloaded, despite the care plan intervention to float the heels. The resident stated the heels were rarely offloaded, that the resident could not move around in bed without staff assistance, and that the heels sometimes hurt. The DON agreed the resident’s heels should have been offloaded, and the observations continued even after the concern was shared with the NHA and DON.
Failure to Follow Fall-Risk Transfer Interventions
Penalty
Summary
The facility did not ensure that a resident with hemiplegia and hemiparesis received adequate supervision and assistance devices to prevent accidents. The resident’s MDS indicated intact long- and short-term memory, impairment on one side of the upper and lower extremities, and the need for substantial to maximal assistance with bed mobility and transfers, with one fall since admission. The care plan identified the resident as needing assistance of one person with a gait belt and pivot transfer because of right-side flaccidity, and also included a fall-risk intervention to remove the wheelchair from the resident’s room while the resident was in bed after a prior unwitnessed fall during a self-transfer. Surveyors observed the resident self-transferring from the bed to the wheelchair and later from the wheelchair back to bed. A CNA stated the resident was not considered a fall risk, said the resident could stand unassisted, and was unaware of the fall-risk status or the intervention to keep the wheelchair away from the bedside while the resident was in bed. A later observation showed the resident in bed with the wheelchair at bedside, and an LPN UM stated the resident remained a fall risk and that the intervention to not leave the wheelchair at bedside was active. The DON stated the fall-risk interventions may have been intended for another resident. A therapy evaluation was ordered to evaluate the resident’s transfer status.
Oxygen Therapy Not Provided as Ordered
Penalty
Summary
The facility did not provide necessary respiratory care and services for a resident receiving oxygen therapy. R33, who was admitted with a diagnosis of pulmonary fibrosis, was observed in bed with a nasal cannula in place while receiving oxygen from a concentrator set at 4.5 liters per minute. During the observation, a water container was attached to the concentrator but was not connected to the oxygen tubing, and the oxygen was being delivered without humidification. The resident’s physician order specified oxygen at 3 liters per minute via nasal cannula continuously. The facility’s oxygen administration policy stated that nasal cannula oxygen requires humidification at flow rates greater than 4 liters per minute. When asked, the DON stated she had not looked at the concentrator and was not sure how many liters the resident was receiving or whether humidification was needed. Later, the LPN Unit Manager observed the resident receiving 4.5 liters per minute without humidification and stated she would look into why the oxygen was set so high and why humidification was not connected. A new concentrator was later observed delivering 3.5 liters of humidified oxygen, and the LPN Unit Manager reported that a new order had been obtained for oxygen between 3 and 5 liters per minute.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility did not ensure the medication error rate remained below 5 percent; surveyors determined the rate was 12 percent, with 3 errors out of 25 opportunities. The deficiency involved one resident, R5, who was observed receiving enteral medications through a gastrostomy tube in a manner that did not follow the facility policy and procedure or current standards of practice. During the observation, RN-J placed carvedilol 6.25 mg, Eliquis 5 mg, and amlodipine 10 mg into a medication sleeve, crushed the three medications together, mixed them with water, and administered them through R5’s gastrostomy tube. The facility policy required each medication to be administered separately unless a physician order and pharmacist review documented the risks and benefits of combining medications. R5 had only a standing order allowing medications to be crushed as appropriate, and no documentation was found of a pharmacist consultation or prior order authorizing the medications to be combined. A later physician order allowing all medications to be given combined via G-tube was obtained after the observation and after the concern was discussed with DON-B.
Vaccination Offer and Refusal Documentation Not Completed
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after the facility did not ensure pneumococcal immunizations were offered or refused as eligible to residents. For R30, who was admitted with diagnoses including aphasia, hemiplegia, and hemiparesis, the Wisconsin Immunization Registry had no vaccination administrations on record. The facility's infection prevention and control policy stated that education would be provided to residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines, and that documentation would reflect the education provided and whether the resident received the immunizations. However, on interview the DON stated that R30 had refused vaccinations, but there was no consent form obtained and no risk-versus-benefit discussion documented for the refusal. Later, the DON stated that R30 now wanted to receive the influenza vaccine and would be getting it that day, and that education on the risks and potential benefits should be explained to and documented in the resident's record.
Missing COVID-19 Immunization Documentation
Penalty
Summary
The facility did not ensure medical records contained documentation related to COVID-19 immunizations for 1 of 5 residents reviewed for immunizations. R30 was admitted with diagnoses including aphasia, hemiplegia, and hemiparesis. The admission MDS documented that R30 had intact long- and short-term memory, could recall the current season, the location of the room, and staff names/faces, and was independent with daily cognitive decision making. The Wisconsin Immunization Registry had no COVID-19 vaccination administrations on record for R30, and surveyor review of the electronic medical record did not locate documentation showing whether R30 was offered, received, or declined the COVID-19 immunization. The facility's Infection Prevention and Control Program policy stated that documentation would reflect the education provided and details regarding whether the resident or staff received the vaccine. When asked about R30's COVID vaccination status, the DON stated that R30 refused vaccinations, but there was no consent form or risk-versus-benefit form documenting the refusal. The DON later stated that education regarding the risks and potential benefits should be explained to the resident and documented in the resident's record, but no additional information was provided.
Failure to Prevent Resident-to-Resident and Staff-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from various forms of abuse, including physical, verbal, and sexual abuse, as well as neglect, as evidenced by multiple incidents involving both resident-to-resident and staff-to-resident interactions. In one case, a cognitively intact resident reported that a severely cognitively impaired resident inappropriately touched her breast on two occasions during hugs, with the second incident perceived as intentional. The resident stated she would no longer allow the other resident to hug her, and no further incidents were reported. Another incident involved a severely cognitively impaired resident who was verbally threatened with sexual assault by another cognitively intact resident during care provided by CNAs. The threatening resident made repeated inappropriate comments and threats in the presence of staff. Additionally, a physical and verbal altercation occurred between two cognitively intact residents in the courtyard, where racial slurs were exchanged, and both residents engaged in physical aggression, resulting in one resident being slapped and the other being hit in the face. Both residents declined to press charges after the incident was reported to the police. A separate event involved an agency CNA who was overheard by an LPN yelling at a cognitively intact resident, instructing her to roll over by herself in a loud and inappropriate manner. The LPN intervened, removed the CNA from the room, and escorted her out of the facility. The resident denied any physical harm but confirmed the verbal abuse. The facility's policy on abuse, neglect, and exploitation was reviewed, and it was confirmed that these incidents constituted failures to prevent and prohibit all types of abuse as required.
Failure to Timely Report Abuse, Neglect, or Theft Allegations
Penalty
Summary
The facility failed to ensure that reportable allegations of abuse, neglect, or theft were reported to the State Agency (SA) in a timely manner and did not notify law enforcement as required. In one instance, a cognitively intact resident with multiple medical conditions was subjected to verbal abuse by a CNA, which was witnessed by an LPN. Although the CNA was immediately removed from the facility and the Administrator and DON were contacted, the mandated 24-hour report to the SA was not submitted until five days after the incident. The Administrator attributed the delay to system issues with the State's online reporting portal and did not notify law enforcement. In another case, a cognitively intact resident reported missing cash after staff returned money that had been given to them. The incident was reported to the SA, but law enforcement was not notified, as the Administrator was unaware of the requirement to do so when a crime is suspected. Additionally, a third cognitively intact resident reported feeling verbally abused by staff, with the information coming from a hospital assessment. The Administrator investigated the incident but did not report it to the SA, believing it was unnecessary since the resident had not reported it directly to the facility. The facility's policy required immediate reporting of all alleged violations to the Administrator, SA, adult protective services, and law enforcement when applicable, but these procedures were not consistently followed.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into abuse allegations involving three residents. In the first case, a cognitively intact resident reported that another resident with severe cognitive impairment touched her breast on two occasions, with the second incident perceived as intentional. The incident was reported to staff, but the facility did not complete a comprehensive investigation or contact law enforcement, as required by policy. In the second case, a resident with paraplegia made sexually inappropriate threats toward a severely cognitively impaired resident in the presence of staff. Although staff intervened verbally, the facility did not conduct a thorough investigation or notify the police, citing the residents' lack of desire to press charges as the reason for inaction. In the third case, a cognitively intact resident reported to hospital staff that he felt verbally abused and intimidated by facility staff. The facility received this information soon after the resident's hospital admission but did not initiate a timely investigation, with the administrator stating the investigation occurred over a week after learning of the allegation. These failures to promptly and thoroughly investigate abuse allegations, as well as to notify appropriate authorities, were contrary to the facility's own policies and procedures.
Failure to Update Care Plan After Change in Medication Self-Administration Status
Penalty
Summary
The facility failed to revise the care plan for one resident after a change in the resident's medication self-administration status. The resident, who had multiple diagnoses including end stage renal disease, asthma, type 2 diabetes mellitus, and a history of sudden cardiac arrest, was previously permitted to self-administer medications as documented in the care plan. However, after repeated incidents of non-compliance, such as hoarding medications, leaving them at the bedside, and not taking them as scheduled, the DON determined it was no longer safe for the resident to self-administer medications. This decision was supported by a self-administration evaluation indicating the resident was not safe to self-administer medications. Despite this change, the care plan was not updated to reflect the resident's new status. Interviews with the resident, DON, and Administrator confirmed that the care plan continued to state the resident could self-administer medications, and no updated care plan was found. The DON acknowledged responsibility for revising the care plan and admitted the update was missed during the most recent quarterly review.
Failure to Inform Family of Care Conferences
Penalty
Summary
The facility failed to inform a family member of care conferences and provide sufficient notice in advance for a resident's care planning. The facility's policy requires that residents' choices in individuals to be included in the care planning process be honored, and efforts should be made to schedule conferences at convenient times for the resident or their representative. However, there was no documented evidence that the resident's family member was invited to participate in the development of the initial care plan or informed in advance of subsequent care conferences. The resident, who was cognitively intact, expressed a desire for her family member to be involved in all aspects of her care. The family member reported receiving a last-minute phone call from the Social Services Director about a care plan conference, which was the only invitation she had received. The Social Services Director admitted there was no system to track invitations to family members and acknowledged that the family member was not informed in advance of the care conference. The Director of Nursing stated that it was expected for family members to be invited in advance to care plan conferences.
Failure to Provide Nail Care to Resident with ADL Deficit
Penalty
Summary
The facility failed to provide necessary nail care to a resident who was unable to perform this activity of daily living independently. The resident, who was admitted with paraplegia and had functional limitations in both upper and lower extremities, was dependent on staff for personal hygiene. Despite being cognitively intact, the resident's care plan did not specifically address nail care, and the facility's policy on nail care was not followed. The resident's fingernails extended approximately one-half inch beyond the tips of his fingers and appeared thick, indicating a need for staff assistance in trimming them. During observations and interviews, it was revealed that the resident had not been offered nail care by the staff, and the Director of Nursing suggested that it was the resident's responsibility to request nail care due to his alert and oriented status. The Certified Nurse Aide mentioned that nail care was typically provided on shower days but was unsure if the resident had been asked about his nail care needs. The resident expressed a lack of knowledge on how to get his nails trimmed and stated that no staff member had offered assistance. Eventually, staff had to soak the resident's nails to soften them for trimming, indicating a delay in addressing the resident's personal hygiene needs.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were ordered and provided for two residents, R12 and R2, which put them at risk for deterioration of their pressure ulcers. For R12, the facility received wound care orders from the hospital upon the resident's admission, but these orders were not implemented until several days later. The Assistant Director of Nursing (ADON) received the treatment orders from the Medical Director but delayed their implementation, resulting in a lack of treatment for R12's pressure ulcers until five days after admission. For R2, the facility did not apply the prescribed wound vacuum (wound vac) system for the resident's pressure ulcer treatment in a timely manner. Although the wound vac was delivered to the facility, it was not applied until three days later. In the interim, a wet to dry dressing was applied without a physician's order, and there was no documented evidence of any wound treatment on one of the days before the wound vac was started. The Unit Manager (UM) confirmed the delay and the lack of proper orders for the interim dressing. The Director of Nursing (DON) confirmed the deficiencies in both cases, acknowledging the lack of timely implementation of treatment orders and the absence of proper documentation for the interim dressing applied to R2. These failures highlight the facility's inability to provide timely and appropriate pressure ulcer care for the residents, as evidenced by the lack of documented treatment and the delay in implementing physician orders.
Inadequate Care for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with a feeding tube, which had the potential to increase the risk of infection. The resident, who was cognitively intact and required tube feeding due to dysphagia, did not have physician orders for the care and treatment of the feeding tube insertion site. Observations revealed that the enteral feeding and water flush bags were not labeled with the date, time, or initials of the person who prepared them, contrary to the facility's policy and current standards of practice. During an observation, it was noted that the resident's feeding tube insertion site had a dressing dated two days prior, with areas of dried blood, indicating that the site had not been cleaned or the dressing changed as required. The Unit Manager confirmed that the dressing should be changed every night, but it had not been done. Additionally, the syringe and container used for the feeding tube were also dated two days prior, despite the requirement for daily changes. The Director of Nursing confirmed that the failure to label and change the enteral feeding and water flush bags, as well as the syringe and container, every 24 hours was an infection control concern. Furthermore, the feeding pump had a build-up of dried enteral feeding formula, and there was uncertainty about the responsibility for cleaning the pump, which should be done regularly. These oversights in care and maintenance of the feeding tube and related equipment contributed to the deficiency identified by the surveyors.
Medication Availability Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the availability of medications for two residents, leading to significant deficiencies in care. Resident 5, who was admitted with conditions including spondylosis and polyosteoarthritis, underwent outpatient surgery for a left ankle bone infection. Despite a physician's order for hydrocodone-acetaminophen to manage post-operative pain, the resident did not receive the medication as prescribed. On multiple occasions, the resident was given only one tablet instead of the ordered two, and eventually ran out of medication entirely. The resident reported severe pain and was unable to enjoy activities due to the lack of pain management. The facility's Director of Nursing acknowledged that the medication should have been available from the contingency box, indicating a failure in the medication reordering process. Resident 2, admitted with diagnoses including an open wound and chronic osteomyelitis, was prescribed cefepime, an antibiotic, to be administered intravenously. However, the resident did not receive the first dose until 22 hours after admission, and 31 hours after the last dose was administered at the hospital. The delay was attributed to the medication not being available in the facility's contingency kit and issues with the pharmacy delivery schedule. The Director of Nursing confirmed that new admissions typically do not receive medications until the following day, and there was a lack of clarity regarding the facility's ability to order medications for immediate delivery. Interviews with staff revealed a lack of communication and coordination in the medication ordering process. Licensed Practical Nurses and the Unit Manager indicated that there were contingency measures in place for obtaining medications, but these were not effectively utilized. The Director of Nursing admitted that the facility had the capability to order medications for stat delivery, but this was not executed in a timely manner for Resident 2. The deficiencies highlight significant lapses in the facility's medication management system, impacting the residents' care and comfort.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to serve food at an appetizing temperature for a resident, identified as R5, who was reviewed for food palatability. R5, who was cognitively intact, reported that meals, particularly breakfast, were served lukewarm and bordered on being cold, despite having good flavor. R5 had made multiple complaints about the food temperatures. During an observation, a test tray of biscuits and gravy was served 15 minutes after the food cart was delivered, and the temperature was measured at 110 degrees Fahrenheit, which was confirmed by the Dietary Manager (DM) to be too low for palatability. The facility's policy on food preparation emphasized serving food at a safe and appetizing temperature. However, the DM acknowledged that residents had complained about food temperatures and noted that the insulated cover used for meal delivery might not be sufficient. The DM also mentioned that sometimes staff did not deliver meal trays quickly enough, contributing to the problem. The holding temperature for the breakfast meal was recorded at 180 degrees Fahrenheit, indicating that the issue arose during the delivery process rather than food preparation.
Infection Control Breach During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during the treatment of a pressure ulcer for a resident diagnosed with paraplegia and a pressure ulcer of unspecified site. During an observation, an LPN was seen taking a treatment cart into the resident's room and placing unused supplies back into the cart after completing the treatment. The supplies included a bottle of Dakin's solution, gauze pads, a tube of Santyl, and foam bordered dressings. This practice posed a risk of cross-contamination as the supplies were exposed to the resident's environment and then returned to the cart without proper sanitization. The LPN admitted to occasionally taking the treatment cart into the room to keep supplies tidy, although she acknowledged that the supplies had not been opened. The Director of Nursing confirmed that this practice was an infection control concern and that the supplies should have been left in the resident's room to prevent potential cross-contamination. The DON also stated that she had not previously observed the LPN engaging in this practice.
Failure to Address Resident's Hearing Loss in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing a resident's hearing loss, as observed during a survey. The resident, who was admitted with diagnoses including urinary tract infection, moderate protein-calorie malnutrition, disease of the pericardium, and anemia, was noted to have intact cognition and required assistance with dressing. Despite being assessed as having hearing aids and adequate hearing, the resident reported not wearing the aids because they were disliked and ineffective. The surveyor observed that staff had to speak directly into the resident's ear for effective communication, indicating a gap in the care plan. Interviews with facility staff, including CNAs and the ADON, revealed that the resident's refusal to wear hearing aids was known, but no care plan or interventions were in place to address this issue. The CNA Kardex also lacked guidance on how to communicate with the resident effectively. The DON acknowledged the oversight in initiating a care plan for the resident's hearing loss and hearing aids, which contributed to the deficiency noted by the surveyor.
Resident Prescribed PRN Ativan Without End Date
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications ordered on an as-needed (PRN) basis. Specifically, a resident was prescribed Ativan, an anti-anxiety medication, to be taken every eight hours as needed, without an end date. This oversight was identified during a surveyor's review of the resident's physician orders, which revealed the absence of a specified duration for the PRN medication. The resident in question had a complex medical history, including traumatic hemorrhage of the cerebrum, chronic respiratory failure, chronic obstructive pulmonary disease, schizophrenia, major depressive disorder, and anxiety. Despite these conditions, the facility's policy mandates that each resident's drug regimen be managed to promote their highest practicable well-being, free from unnecessary drugs. The director of nursing acknowledged the oversight when it was brought to their attention by the surveyor, indicating that the lack of an end date for the PRN Ativan was an error.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as observed during a survey. Two residents were affected by medication administration errors. One resident, diagnosed with hypothyroidism and glaucoma, was administered levothyroxine after breakfast instead of on an empty stomach, contrary to medication guidelines. Additionally, the same resident received Timolol Maleate eye drops that were not discarded four weeks after opening, as per the manufacturer's instructions. These errors were observed during a medication administration session by an LPN. Another resident, diagnosed with depression, was administered 150 milligrams of immediate release Venlafaxine instead of the prescribed 150 milligrams of extended release Venlafaxine. The LPN administering the medication did not have the extended release tablets available and was instructed to use immediate release tablets from the backup supply. This resulted in the resident receiving a total of five 37.5 milligram tablets of immediate release Venlafaxine. The LPN acknowledged the error and indicated that the resident's doctor would be contacted immediately. These incidents contributed to a medication error rate of 10.71 percent, exceeding the acceptable threshold.
Medication Error: Immediate vs. Extended Release Venlafaxine
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A resident, identified as R24, was administered 150 milligrams of Venlafaxine immediate release instead of the prescribed 150 milligrams of extended release Venlafaxine. This error occurred when an LPN, identified as LPN-D, administered the medication. The LPN initially poured 37.5 milligrams of Venlafaxine from the resident's medication card and, upon realizing the absence of the extended release tablets in the backup supply, was instructed to give additional immediate release tablets to make up the total dosage. Consequently, the LPN administered five 37.5 milligram tablets of immediate release Venlafaxine to the resident. The resident, R24, had been admitted to the facility with a diagnosis of depression and had a physician's order for Venlafaxine extended release 150 milligrams once daily. The error was identified during a surveyor's observation and subsequent review of the resident's current physician orders. The LPN acknowledged the error and indicated that she would contact the resident's doctor immediately. The Nursing Home Administrator and Director of Nurses were informed of the findings, but no additional information was provided regarding the reason for administering the incorrect form of Venlafaxine.
Unqualified Food Service Manager Employed
Penalty
Summary
The facility failed to employ a qualified full-time Food Service Manager (FSM) with the required certification and skill sets for 52 of 53 census residents. The job description for the FSM position requires a graduate of an accredited course in dietetic training approved by the American Dietetic Association, with a minimum of two years' experience in a supervisory capacity in a hospital, nursing care facility, or other related medical facility, and training in cost control, food management, and diet therapy. However, during an interview, the FSM admitted to not having started the necessary certification course since beginning the position in October 2023. Additionally, the FSM's resume did not reflect any food management positions or experience. The Administrator was unaware of the FSM's lack of training and acknowledged that the FSM should have had the required training before being hired.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to two residents and their representatives during emergent hospital transfers. The policy requires that such notices include specific reasons for the transfer, the effective date, the location of transfer, and information on appeal rights. However, upon review of the electronic medical records for two residents, there was no evidence that these notices were provided during their hospital transfers. This oversight was confirmed through interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), who were unaware of the requirement to provide written notices to residents and their representatives. The deficiency was identified during a review of the facility's policy and procedures, which clearly state the necessity of providing written notices in a language and manner understandable to the resident and their representative. Despite this policy, the facility's practice during emergent transfers involved only verbal communication and documentation for emergency services, without providing the required written notice to the residents or their representatives. This lack of compliance with the policy was evident in the cases of two residents who were transferred to the hospital without receiving the necessary documentation, leaving them and their representatives uninformed about the transfer details and their rights to appeal.
Failure to Follow Physician Orders for Weight Monitoring
Penalty
Summary
The facility failed to ensure physician orders for weight monitoring were followed for three residents, which could lead to unrecognized significant weight changes due to the lack of established baseline weights. The facility's policy required weekly weight monitoring for newly admitted residents for four weeks. However, for Resident 2, weights were only recorded on two occasions, missing the required weekly checks. Resident 2 had multiple diagnoses, including hemiplegia, congestive heart failure, and obesity, which necessitated careful monitoring. Similarly, Resident 30's weight records showed inconsistencies, with weights taken on non-consecutive weeks, failing to adhere to the weekly schedule. Resident 30 had complex medical conditions such as morbid obesity, end-stage renal disease, and hypertension. For Resident 32, only one weight was recorded during the specified period, despite having conditions like heart failure and acute kidney failure. Interviews with staff, including an LPN and the DON, confirmed the expectation that weights should be taken as ordered, highlighting a lapse in compliance with physician directives.
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 376 citations issued within 25 miles in the last 12 months — including the 12 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 Kenosha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avina On 32nd | 1.1 mi | ★★★★★ | 19 | 0 |
| Clairidge House | 1.9 mi | ★★★★★ | 29 | 0 |
| Avina Of Kenosha | 3.7 mi | ★★★★★ | 1 | 0 |
| Waters Edge Health And Rehabilitation Center | 3.8 mi | ★★★★★ | 2 | 0 |
| Brookside Care Center | 3.8 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sheridan Health And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.