Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 St. Anne's Salvatorian Campus during CMS and state inspections, most recent first.
Failure to Prevent and Accurately Assess Pressure Injuries: A resident admitted without pressure injuries and assessed as high risk developed two facility-acquired wounds on both lower legs. Staff did not identify resident-specific pressure-relief interventions, and the initial nursing assessment documented the wounds as open lesions even though photos later showed slough and the DON confirmed they should have been classified as unstageable pressure injuries. Staff also identified possible causes such as leg crossing, wheelchair pressure, leg curvature, and the resident’s habit of lying with legs off the bed, but these factors were not addressed in the care plan at discovery.
The facility failed to maintain its infection prevention and control program when an RN used the wrong wipe to disinfect a shared glucometer between resident blood sugar checks, despite the meter being used for multiple residents on the unit. Surveyors also found no evidence that a COVID-19 outbreak affecting residents and staff was reported to the local health authority. The ADON/IP and facility leadership stated no additional outbreak documentation was available.
Infection Preventionist Lacked Required Specialized Training: The ADON began serving as the IP in August 2025, but there was no evidence of specialized infection prevention and control training or CDC course completion before taking the role. During survey interviews, the ADON/IP stated there was no certification, had not completed the CDC training, and was not aware of the IP role in the water management program. The regional nurse consultant confirmed the ADON/IP was only enrolled in the CDC IP course after the issue was identified.
Missing and Incomplete Transfer and Bed-Hold Notices: A facility failed to provide required written transfer and bed-hold notices for several residents sent to the hospital. Notices were missing or incomplete for residents with acute changes in condition such as chest pain, vomiting, falls, shortness of breath, and altered status, and some forms lacked required details like the reason for transfer, reserve bed-hold payment, correct payor source, or evidence that the resident or POA was notified. The surveyor confirmed that no notice existed for multiple hospitalizations.
A resident with dementia, CHF, Lewy body neurocognitive disorder, and hospice services returned from the hospital with discharge paperwork showing DNI/DNR status and was observed wearing a purple DNR/DNI bracelet, yet the EMR, physician orders, and care plan still showed full code. Staff said the floor nurse reviews readmission paperwork, but the RN was unaware of the code status change, and there was no documentation of POA contact until the code status was later updated in the EHR.
PRN Psychotropic Orders Exceeded 14-Day Limit Three residents had active PRN benzodiazepine orders that remained in place beyond the 14-day limit without documented justification from the prescribing practitioner. The residents had diagnoses including dementia, anxiety, schizophrenia, chronic pain, and hospice enrollment, and the records showed PRN clonazepam or lorazepam was administered while the orders remained open-ended. The DON stated pharmacy and psychoactive committee reviews occurred, but the missing stop dates were overlooked.
Failure to complete PASARR Level II screening for a resident with schizoaffective disorder, dementia with behavioral disturbance, anxiety, and unspecified intellectual disabilities. The Level I PASARR was positive for a major mental disorder and psychotropic use, and the resident remained in the facility after the 30-day hospital discharge exemption expired. The DON/ADON and admissions staff confirmed no Level II was in the chart.
A resident with Alzheimer’s disease and dementia had a right shoulder dislocation, was sent out for evaluation, and returned with an order for a sling and shift-by-shift monitoring. The care plan was not revised to include the sling, how it should be used, or interventions for the resident’s refusals to wear it, and staff interviews confirmed the plan had not been updated to reflect the resident’s changed care needs.
A resident admitted with COPD, chronic respiratory failure with hypoxia, acute bronchitis, and asthma did not have evidence that the COVID-19 vaccine was offered on admission, and the EMR lacked documentation of POA consent or refusal and the last COVID-19 vaccine date. The ADON/IP stated resident vaccines are reviewed and offered on admission and that POA consent should be obtained and documented, but later acknowledged the vaccine had been missed on admission.
A resident with hemiplegia and multiple comorbidities was repeatedly assessed on the MDS and by therapy as dependent for bed mobility, a status that staff stated requires two-person assist. However, the resident’s care plan continued to list only one-person assist for bed mobility and referenced half side rails, while a later assessment identified use of a bed bar/enabler bar. During in-bed care, a CNA raised the bed, rolled the resident onto the side affected by hemiplegia and away from herself, and then reached for a towel without maintaining control, allowing the resident to continue rolling and fall from the bed, resulting in a head laceration requiring sutures and a questionable rib fracture. Surveyor review found that the care plan did not reflect current assessments, that the resident was treated as a one-person assist despite being documented as dependent, and that the resident was rolled away from the caregiver on a raised bed without continuous hands-on control, leading to the accident.
A resident with CHF, prior stroke, hypertension, and new A Fib returned from the ED with a verbal order for Metoprolol Tartrate 25 mg daily for rate control, but the order was not implemented for several days and did not appear on the MAR for that month. Hospice RNs faxed metoprolol orders and documented ongoing A Fib and tachycardia, yet the medication was only entered later, with parameters to hold for HR < 60 or systolic BP < 100. Nursing staff then administered metoprolol on multiple occasions when the resident’s HR and/or systolic BP were below those parameters. Interviews with the DON and an RN showed that floor nurses were responsible for reviewing hospital and hospice orders, that hospice typically communicated via fax, and that the RN did not review hospice notes, resulting in delayed implementation of the order and failure to follow the ordered hold parameters.
A resident with a history of joint replacement and mental health conditions reported to therapy staff that a PTA made her uncomfortable by patting her buttocks. Although the incident was reported internally and the PTA was suspended pending investigation, the facility did not notify law enforcement as required by policy, citing the resident's refusal. Staff interviews confirmed awareness of the allegation and the lack of external reporting.
A medication technician prepared a dose of Lactulose for a resident with severe cognitive impairment but did not administer it immediately when the resident was asleep. Instead, the medication was returned to the cart in open cups and later administered to the resident, contrary to facility policy requiring unused medications to be discarded.
A Med Tech failed to perform hand hygiene before entering a resident's room and did not wear gloves while administering oral liquid medication to a resident on Enhanced Barrier Precautions for wounds. The Med Tech used bare hands to assist with medication and dabbed the resident's mouth, then discarded items and attempted to use an empty hand sanitizer dispenser before leaving to use another dispenser. Staff interviews confirmed that proper infection control protocols were not followed.
A resident with hypertension and other conditions was not given his prescribed morning medications after an RN, based on the resident's statement, instructed a medication technician to withhold them. The MAR was not signed, and the RN documented a refusal without verifying if the medications were actually taken. Later that day, the resident experienced a hypertensive crisis and required hospital transfer. The DON confirmed the RN did not properly investigate the situation.
A resident at risk for pressure injuries developed a stage 2 coccyx pressure injury and a DTI on the right heel, which were not properly assessed or documented. The care plan was not updated with necessary interventions, and communication between facility and hospice staff was unclear, leading to inadequate wound care and the resident's declining condition.
The facility failed to ensure resident safety, leading to multiple unwitnessed falls and inadequate supervision. A resident with severe cognitive impairment and high fall risk sustained several falls, including one resulting in a fracture, without thorough root cause analyses or effective interventions. Another resident experienced falls due to equipment issues, with insufficient investigation and lack of staff training on safe transfers. Additionally, medication storage was not adequately managed on one unit.
The facility did not conduct a comprehensive facility-wide assessment, failing to document staffing ratios and adequately assess the dual role of the DON as the IP. The Water Management Committee and potential infection risks were also not evaluated, potentially affecting all 43 residents.
The facility failed to implement effective infection control measures, as observed in the handling of glucometers and laundry, and in the management of water systems. Two residents were tested for blood sugar using a shared glucometer that was not sanitized between uses, and the facility lacked a policy for glucometer cleaning. Additionally, laundry was delivered without covers, and the water management plan lacked documentation of control measures for preventing Legionella. The facility also did not maintain an updated list of staff fit-tested for N95 masks, and infection surveillance and tracking were inadequate.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses and unmet resident needs. Surveyors observed residents waiting extended periods for assistance, with some reporting unresponsive CNAs and frustration with floaters. The facility's schedules lacked designated charge nurses, and the Scheduler was unaware of staffing requirements, highlighting deficiencies in staffing practices.
The facility failed to provide written transfer notifications to six residents and did not notify the State Ombudsman. Confusion among staff about responsibilities led to this deficiency. The residents, with conditions like dementia and chronic kidney disease, were transferred to the hospital without the required documentation.
A resident who was initially continent of bowel experienced a decline in continence, but the facility failed to conduct a comprehensive assessment or implement new interventions. The facility did not document or monitor the resident's bowel movements, and the DON acknowledged that the recording system was not activated, resulting in a lack of records to determine the cause of incontinence.
A resident with multiple medical conditions and a BIMS score indicating cognitive intactness was found with medications left at her bedside without an assessment or order for self-administration. The resident confirmed that staff sometimes leave medications in her room, depending on the nurse. The facility did not provide additional information when notified of the findings.
A resident with Quadriplegia and cognitive intactness was unable to reach their call light due to improper placement by staff, leading to unmet needs for assistance. The CNA, unfamiliar with the resident's specific call light system, required guidance from the resident to secure it properly. Facility administration acknowledged the deficiency, emphasizing that all staff should be trained to ensure call lights are within reach.
A resident's code status was not clearly indicated in their medical record, leading to a deficiency in honoring their right to formulate an advance directive. Despite expressing a wish for a DNR status, the resident's code status was not documented, and there was no physician's order. The facility considered the resident a full code due to the absence of a signed state DNR form, causing confusion and lack of clarity in an emergency.
The facility failed to maintain the confidentiality of two residents' medical records. Medication Administration Records (MAR) and medication cards were left unattended and visible on the medication cart, contrary to facility policy. The Nursing Home Administrator was informed of these breaches, but no further information was provided.
The facility failed to complete Level 2 PASARR assessments for two residents with mental illness and developmental disabilities. One resident with severe cognitive impairment and multiple psychiatric diagnoses did not have a Level 2 PASARR, while another resident with Down Syndrome also lacked this assessment. The Referral Specialist did not receive notifications to complete the Level 2 PASARRs, and the Nursing Home Administrator was informed but did not provide further information.
The facility failed to complete neurological checks for two residents after unwitnessed falls, as required by policy. One resident with severe cognitive impairment did not receive checks for multiple falls, while another resident's checks were undocumented despite being initiated. Staff interviews confirmed the expectation for neuro-checks, but documentation was missing.
A resident with ESRD did not receive appropriate dialysis care at the facility. The resident lacked physician orders for dialysis, daily monitoring of the dialysis access site, and consistent communication between the facility and the dialysis center. The care plan did not address the dialysis access site or how staff would provide care. Facility staff did not document monitoring of the dialysis site, and communication with the dialysis center was inconsistent.
A resident with severe cognitive impairment and complete dependence on staff for mobility was observed with a bed rail, but the facility failed to regularly assess the risk of entrapment and review the risks and benefits of its use. The resident's condition had changed, making them dependent, yet the facility did not complete a side rail assessment and risk screen after this change. Interviews with staff revealed inconsistencies in the process and frequency of assessments, and the resident was not included in monthly safety audits.
A resident with depression and anxiety expressed a desire to transfer to another facility, but the LTC facility failed to provide timely social services and communication. The resident's care plan was not effectively followed, and there was a lack of documentation and follow-up from the Life Coach responsible for coordinating the transfer. This resulted in increased anxiety and depression for the resident, as their needs and requests were not adequately addressed.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 8%. An RN administered incorrect doses of Furosemide and Atorvastatin to a resident, deviating from the prescribed orders. The RN initially prepared medications but had to retrieve missing doses from contingency, leading to the errors. The Nursing Home Administrator was notified, but no additional information was provided.
The facility did not ensure insulin vials and pens were dated when opened, as required by their policy. Insulin for three residents was found opened and used without being dated, both in the medication cart and refrigerator. The RN and DON were informed, but no further information was provided.
A facility failed to ensure proper collaboration and communication with hospice services for a resident on hospice care, leading to inadequate wound care management. The resident had unstageable pressure injuries and developed a new wound that was not thoroughly assessed or documented. The hospice nurse was unaware of their sole responsibility for wound care, resulting in incomplete assessments and documentation. This deficiency underscores the need for clear communication and documentation between facility and hospice staff to ensure continuity of care.
A facility failed to maintain an antibiotic stewardship program for a resident receiving prophylactic vancomycin for c-diff. The IP/DON was unaware of the treatment, and the antibiotic use was not monitored or reviewed during infection control surveillance. The facility's policy did not specify tracking for prophylactic antibiotics, leading to a gap in the stewardship program.
A facility failed to report an allegation of physical abuse involving a resident with multiple medical diagnoses, including psychosis and intellectual disabilities, to the State Survey Agency as required. The incident involved a misunderstanding in the dining room where the resident was reportedly slapped, but later denied any physical contact. Despite this, the facility's policy mandates immediate reporting of all abuse allegations, which was not adhered to, as confirmed by the Administrator and Nurse Consultant.
A facility failed to investigate an allegation of physical abuse involving a resident who was reportedly slapped by a male staff member in the dining room. Despite the resident later denying the incident, the facility did not conduct a formal investigation as required by its policy, which mandates immediate investigation of abuse allegations. This failure was confirmed by interviews with the Administrator and Nurse Consultant.
Failure to Prevent and Accurately Assess Facility-Acquired Pressure Injuries
Penalty
Summary
The facility did not ensure a resident at high risk for pressure injuries received necessary treatment and services to prevent the development of pressure injuries. The resident was admitted without pressure injuries, had a Braden Scale score of 11 indicating high risk, and required extensive assistance with mobility and ADLs. The resident’s care plan identified impaired skin integrity related to decreased ambulation and included general pressure-relief language, but it did not identify resident-specific interventions such as what type of cushion was needed while up in a chair. The resident developed two new wounds on both lower legs that were initially documented by nursing as open lesions on the right and left knees. The initial nursing assessment described the wounds as new, in-house acquired open lesions with measurements, but the nurse stated she was unsure what to categorize them as and did not think they were due to pressure. The nurse also stated the resident crossed the legs while sitting in the wheelchair and moved around a lot, and that the wounds might have developed from shearing. Another nurse later stated the wounds were over prominent areas on the lower legs and could have developed due to the curvature of the legs. Staff also observed the resident lying with both lower legs off the mattress and resting directly on an extra mattress next to the bed, and staff stated the resident liked to lie in that position. The wounds were not accurately assessed when first discovered. Survey review of the initial wound photographs showed slough present in both wounds, and the DON later confirmed the wounds should have been categorized as unstageable pressure injuries. The wound NP also stated the wounds were pressure injuries and described them as full-thickness wounds with slough. The facility did not identify the root cause of the wounds at discovery, and the care plan was not revised at that time to address the staff-identified possible causes, including leg crossing, pressure from the wheelchair, the resident’s leg curvature, and the resident’s preference to lie with legs off the bed. The resident’s wounds were later documented as facility-acquired unstageable pressure injuries to the right and left lower legs.
Infection Control Deficiencies: Improper Glucometer Disinfection and Unreported COVID-19 Outbreak
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveyors identified two infection control concerns: a shared glucometer was not properly disinfected between resident uses, and the facility did not provide evidence that a COVID-19 outbreak in February 2025 was reported to the local public health authority. During observation, an RN used a glucometer on multiple residents on the first floor and cleaned it with a wipe from a container labeled as an instant hand sanitizing wipe. The RN wiped the glucometer for 15 seconds and left it wet to air dry, then later used the same type of wipe again after another resident’s blood sugar check. The RN stated the floor’s glucometer was shared between residents and later acknowledged the wrong wipe had been used. The facility stated the correct wipe was the purple-top germicidal disposable wipe, and the glucometer manufacturer instructions indicated the meter should be cleaned and disinfected after use on each patient using Super Sani-Cloth germicidal disposable wipes. Surveyors also reviewed records showing a COVID-19 outbreak from late January through February 2025 that affected 12 residents and 3 staff members. The Assistant DON, who served as the Infection Preventionist, stated the available binders contained all information the facility had regarding the outbreak and that no additional information was available. Surveyors were unable to locate evidence that the outbreak had been reported to the local health officer, and the facility leadership and regional nurse consultant confirmed no further documentation could be found.
Infection Preventionist Lacked Required Specialized Training
Penalty
Summary
The facility did not ensure the Infection Preventionist (IP) had specialized training in infection prevention and control before serving in that role. The Assistant Director of Nursing (ADON)-C began acting as the IP in August 2025, but during record review and interview there was no evidence that ADON-C had completed specialized infection prevention and control training or CDC training before assuming the position. The facility policy titled Infection Prevention and Control Program, reviewed 8/29/25, states the IP will maintain current knowledge in infectious disease and epidemiology through training provided through the CDC in collaboration with CMS. On 3/24/26, the surveyor met with ADON/IP-C, who stated there was no certification or specialized training and that the CDC training had not been completed. ADON/IP-C also stated the role had been taken over in August 2025. On 3/25/26, ADON/IP-C stated enrollment in the infection prevention and control program occurred only after the issue was brought to the facility's attention, and ADON/IP-C was not aware of the IP role in the facility's water management program. The regional nurse consultant confirmed ADON/IP-C was enrolled in the CDC infection preventionist training course on 3/24/26 but had not yet completed it, and a certificate for the regional nurse consultant could not be located. The facility later provided a certificate for nurse consultant-O showing completion of the CDC Nursing Home Infection Preventionist Training Course dated 7/16/2024, and stated nurse consultant-O also assists with the infection control program.
Missing and Incomplete Transfer and Bed-Hold Notices
Penalty
Summary
The facility did not ensure that required written transfer and bed-hold notices were provided for 5 of 8 residents reviewed for hospitalization: R5, R6, R30, R37, and R1. The report states the notices were to include the date and reason for transfer, location of transfer, duration of bed hold, reserve bed-hold payment, appeal rights, and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. Survey review found that these notices were missing, incomplete, or inaccurate for the identified residents and hospital transfers. R5 had multiple hospital transfers while in the facility. For the 6/14/25 transfer, the facility produced a bed-hold confirmation form that listed the date of transfer, location, payor source, 15-day bed hold, appeal rights, and Ombudsman information, but it did not document the reason for transfer, reserve bed-hold payment daily rate, or signatures showing the resident or representative was notified. For the 12/4/25 transfer, the notice listed Medicare as the payor source even though the resident should have been Medicaid, and it did not indicate a 15-day bed hold. No bed-hold or transfer notice was found for the 7/2/25 hospitalization. The record also showed R5 had a POA and was sent to the hospital after changes in condition including weakness, confusion, unresponsiveness, and coffee-brown emesis. R6, R30, R37, and R1 also had hospital transfers with no evidence that the required notices were provided or, in one case, the notice was incomplete. R6 had hospitalizations for chest pain and projectile vomiting, and the facility confirmed no bed-hold or transfer notices existed for either transfer. R30 had hospitalizations after a fall with decreased oxygen saturation and later shortness of breath; the notice for the 1/31/26 transfer included the required transfer details, reason, appeal rights, and Ombudsman information, but did not document the reserve bed-hold payment daily rate, and no notice existed for the 2/24/26 transfer. R37 had transfers for vomiting and diarrhea, trouble breathing, and increased shortness of breath, and the facility confirmed no bed-hold or transfer notices existed for any of those hospitalizations. R1 was hospitalized for a change in condition with shortness of breath and fluctuating oxygen saturation, and the surveyor found no evidence that transfer and bed-hold notice was provided to the resident or the POA.
Advance Directive Wishes Not Reflected in Resident Record
Penalty
Summary
The facility did not ensure R40’s medical record reflected the resident’s advance directive wishes after readmission from the hospital. R40 had diagnoses including dementia, congestive heart failure, neurocognitive disorder with Lewy bodies, anxiety, and hypertensive heart disease with heart failure, and also received hospice services with an activated POA. The hospital discharge summary documented that R40’s code status was changed to DNI/DNR, and on 4/29/26 R40 was observed wearing a purple DNI/DNR bracelet on the right wrist. Despite the hospital documentation and the bracelet, the facility’s electronic medical record continued to show full code in multiple places. R40’s physician orders still documented full code, the code status shown by R40’s picture in the EMR documented full code, and the care plan continued to list full code until 4/29/26. The resolved care plan showed code status as full code initiated 10/23/23 and revised and resolved 4/29/26, but the current care plans did not include an advance directive care plan for DNR after the full code care plan was resolved. Surveyor review also found no documentation in the record showing staff contacted R40’s POA about the code status change until 4/29/26 at 11:32 a.m., when a regional nurse consultant documented that the hospital records were reviewed, the DON verified DNR with the daughter/POA, and the code status was changed to DNR in the EHR. Facility staff told the surveyor that the floor nurse reviews hospital records on readmission and checks code status, but the RN stated she had not looked at the record and was unaware the code status had changed. The NHA and DON stated they knew the code status had changed but had not yet obtained the state DNR form and had kept the resident as full code.
PRN Psychotropic Orders Remained Active Beyond 14 Days
Penalty
Summary
The facility did not ensure that residents receiving PRN psychotropic medications had orders limited to 14 days. Review of records and interviews identified three residents with active PRN benzodiazepine orders that remained in place beyond the 14-day timeframe without documentation from the attending physician or prescribing practitioner justifying continued use. The facility policy titled Standard Psychoactive Medication Protocol stated that psychoactive medications were to be reviewed for gradual dose reduction as indicated and that non-pharmacologic approaches should be offered. R9 had diagnoses including Alzheimer’s disease, dementia with anxiety and mood disturbance, major depressive disorder, and anxiety disorder, and had severely impaired cognition with a BIMS score of 5. R9’s record showed an active order for clonazepam 0.5 mg every 12 hours PRN for increased agitation, with no end date, and the medication was administered multiple times in March 2026. The medical record did not include documentation justifying PRN clonazepam use beyond 14 days. R6 had diagnoses including paranoid schizophrenia, major depressive disorder, generalized anxiety disorder, and dementia, with a BIMS score of 6. R6 had an active order for clonazepam 2 mg every 6 hours PRN for anxiety, also without a stop date, and received PRN doses in March 2026. R34 had diagnoses including sequelae of cerebral infarction and chronic pain, intact cognition with a BIMS score of 15, and was on hospice for end-of-life care. R34 had an active order for lorazepam 0.5 mg every 3 hours PRN for anxiety, restlessness, dyspnea, and nausea, with no stop date and no documentation supporting continued PRN use beyond 14 days.
Failure to Complete PASARR Level II Screening
Penalty
Summary
The facility failed to complete a PASARR Level II evaluation for a resident who had a positive Level I PASARR screen identifying a major mental disorder and unspecified intellectual disabilities. The resident was admitted with diagnoses including schizoaffective disorder, unspecified dementia with other behavioral disturbance, anxiety disorder, and unspecified intellectual disabilities, and the Level I screen documented that the resident had a major mental disorder, had symptoms suggesting major mental illness, and was receiving psychotropic medication, including Seroquel. The Level I screen also indicated a hospital discharge exemption with a 30-day maximum, but the screen summary did not document the date the screen was completed. Surveyor review of the electronic record found no PASARR Level II in the resident’s chart after the 30-day exemption period expired. The Director of Admissions stated that a Level II would be required for a resident with mental illness and confirmed that the resident should have had a Level II completed because the resident was on Seroquel on admission and had a major mental illness. The Nursing Home Administrator later provided a new Level I screen and an email showing a request for a Level II screen, and stated the previous admissions coordinator had left and PASARR Level II screens had not been completed since then.
Care Plan Not Revised After Right Shoulder Dislocation
Penalty
Summary
The facility did not ensure that R9’s comprehensive care plan was revised after a change in condition when R9 was diagnosed with a right shoulder dislocation. R9 was admitted with diagnoses including Alzheimer’s disease and dementia with anxiety, had severely impaired cognition with a BIMS score of 5, and had an activated POA for healthcare decisions. R9’s existing care plan addressed chronic pain related to a history of a fractured left humerus, but it was not updated after the right shoulder injury and subsequent reduction. Progress notes documented that R9 was sent for x-rays because of guarding the right arm, and the x-ray results showed an anterior subluxation/dislocation of the right shoulder. R9 was sent out for further evaluation and treatment, then returned with an order for a sling to the right arm and shoulder area with monitoring every shift and documentation of refusals every shift. Survey review found the care plan was not revised to include the sling, the frequency for keeping it in place, or interventions related to R9’s refusals to wear it. The CNA care card also did not document sling interventions, and nursing notes showed R9 refused the sling at times. During observation, R9 was sitting in a recliner without the sling and indicated no when asked if the sling should be put on. Staff interviews confirmed the care plan had not been updated to reflect the current care needs.
Failure to Offer and Document COVID-19 Vaccine on Admission
Penalty
Summary
The facility did not ensure that each resident was offered the COVID-19 vaccine when it was available to the facility for 1 of 5 residents reviewed for immunizations. R21 did not have evidence in the EMR of being offered the COVID-19 vaccine upon admission to the facility on 1/9/26, and the immunization tab also lacked documentation of the POA’s consent or refusal and the date of the last COVID-19 vaccine received. The facility policy stated that immunizations are to be offered upon admission, immunization status is to be verified, and consent or refusal is to be documented in the EMR. R21 was admitted with diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia, acute bronchitis, and unspecified asthma, and had an activated healthcare POA effective 1/24/26. The ADON, who also served as the Infection Preventionist, stated that resident vaccinations are reviewed and offered on admission and that verbal consent from an activated POA is to be obtained and documented in the immunizations section. After the concern was raised, the ADON acknowledged that R21 had not been offered the COVID-19 vaccine upon admission and stated that consent was later obtained from the POA and the vaccine was administered on 3/26/26.
Resident Fall From Bed Due to Inadequate Assistance and Inaccurate Care Plan for Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was as free of accident hazards as possible and that adequate supervision and assistance were provided during bed-level care. The resident had multiple diagnoses, including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, syringomyelia, COPD, depression, anxiety, hypertension, and chronic respiratory failure. On both a significant change MDS and a subsequent quarterly MDS, the resident was assessed as "dependent" for bed mobility, which, per the RAI Manual and staff interviews, means the helper does all of the effort and that two or more helpers are required for safe completion of the activity. Therapy documentation from several months also described the resident as dependent in all bed mobility, and staff interviews confirmed the resident could not turn or reposition independently. Despite these assessments, the resident’s care plan, initiated months earlier and not revised, documented that the resident required the assistance of one staff for bed mobility and the use of half bed rails bilaterally for repositioning and bed mobility. A side rail assessment later identified a bed bar/enabler bar as the device in use, and the facility reported that it does not use side rails, only a small horseshoe-shaped grab bar. The care plan was therefore not reflective of the current MDS assessments or the resident’s actual level of assistance needed. The MDS nurse stated that a dependent code requires two-person assist per CMS guidelines and acknowledged that if the care plan indicated one-person assist, then the care plan was not updated or correct. The DON and PTA also stated that being dependent for bed mobility means the resident would require two-person assistance, and staff reported that after the fall the resident was always treated as a two-person assist for bed mobility. The fall event occurred when a CNA was providing in-bed care to the resident in preparation for a shower. The CNA raised the bed to working height and turned the resident onto his right side, away from herself, while the bed was slightly angled per the resident’s preference. The resident, who had left-sided hemiplegia and could not use the grab bar with the affected side, experienced an arm spasm that stopped, and then the CNA reached for a towel placed on the wheelchair next to her. During this moment, the CNA did not maintain control of the resident, and he continued to roll and slid out of bed onto the floor. The CNA reported she was unable to stop him from rolling as it happened quickly. The facility’s own education materials on safe in-bed care emphasized maintaining one-hand contact during turning, not leaving residents unattended on a raised bed, and standing on the side toward which the resident could roll if side rails are not used. The investigation summary stated the facility believed the care plan was followed and did not submit a self-report, but surveyor review concluded that the resident, assessed as dependent for bed mobility, was provided care with only one staff, rolled away from the caregiver, and not adequately controlled, resulting in a fall with head laceration requiring sutures and a questionable rib fracture. Interviews with nursing and therapy staff further clarified the mismatch between documentation and practice. The DON acknowledged that the resident was dependent for bed mobility and could not turn or reposition himself, yet stated that therapy had determined he was a one-person assist, even though therapy notes did not specify this and instead documented dependency. The PTA confirmed the resident could not roll himself at all and was dependent for bed mobility, meaning two-person assist. A CNA reported that before the fall she would roll the resident by herself and that after the hospital return he was always treated as a two-person assist. The NHA disputed that the definition of dependent necessarily required two-person assist, but the surveyor referenced the RAI Manual and staff statements indicating that dependent status includes the need for two helpers for safe completion of the activity. These inconsistencies in assessment, care planning, and actual care practices contributed to the resident being turned and cared for in bed by a single CNA, rolled away from the caregiver, and left without continuous physical control on a raised bed, culminating in the fall and injury. The facility’s investigation summary stated that the bed locks were in proper working order and that this was the resident’s first fall since admission. However, the surveyor noted that the resident’s MDS assessments, therapy documentation, and staff interviews consistently described him as dependent for bed mobility, while the care plan and actual staffing during the incident reflected only one-person assistance. The surveyor also highlighted that the resident was turned onto his right side, leaving his hemiplegic left side exposed and unable to utilize the bed bar, and that the CNA rolled him away from herself contrary to external guidance on dependent rolling techniques, which recommend positioning on the side toward which the resident is to roll and rolling the resident toward the caregiver. These documented actions and discrepancies formed the basis of the deficiency for failure to maintain a hazard-free environment and provide adequate supervision and assistance devices to prevent accidents.
Failure to Implement and Follow Metoprolol Orders and Hold Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was administered and monitored according to physician-ordered parameters and that new cardiac medication orders were timely implemented. The resident, who had diagnoses including CHF, hemiplegia/hemiparesis after stroke, hypertension, and atrial fibrillation, was sent to the ED after a fall and was found to be in A Fib with RVR, likely due to fluid overload. In the ED, oral metoprolol was used for rate control, and upon return to the facility, a verbal physician order dated 11/27/25 directed Metoprolol Tartrate 25 mg once daily for heart failure and A Fib. However, this order was not implemented until 12/1/25, and the November MAR contained no entry for metoprolol. When Metoprolol Tartrate 25 mg was finally entered on the December MAR, it included parameters to hold the medication for HR < 60 or systolic BP < 100. Despite these parameters, the resident received metoprolol on multiple occasions when it should have been held: on 12/2/25 when the pulse was documented as 60, on the morning of 12/9/25 when the pulse was 49, on the morning of 12/14/25 when the systolic BP was 98 and pulse 50, and on the morning of 12/19/25 when the systolic BP was 79. The December MAR showed metoprolol 25 mg once daily starting 12/2/25 and discontinued 12/8/25, then increased to 25 mg twice daily starting 12/9/25, with the same hold parameters, yet the parameters were not followed on the dates noted. Hospice documentation showed that on 11/28/25 a hospice RN faxed a new order for metoprolol 25 mg once daily to control A Fib after the ED visit, and on 12/1/25 the same hospice RN documented that the metoprolol order from the prior week was not in the electronic system and refaxed it, instructing facility staff that the resident needed a dose that day due to ongoing A Fib with HR in the 115–130s. Interviews with the DON and an RN revealed that floor nurses are responsible for reviewing hospital return paperwork and implementing hospice faxed orders, and that hospice is expected to communicate new orders directly to the nurse. The RN stated she does not review hospice notes, and both the RN and DON acknowledged that medication hold parameters ordered by the physician should be followed. The surveyor determined that the metoprolol order was not implemented as ordered and that the medication was administered on several dates despite vital signs being outside the ordered parameters.
Failure to Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of abuse to local law enforcement as required by its own policy and regulatory expectations. A resident, who was cognitively intact and had a history including joint replacement and mental health diagnoses, reported to the therapy director that a physical therapy assistant (PTA) had made her feel uncomfortable by patting her buttocks. The incident was immediately reported to the social worker and the former administrator, and the PTA was suspended pending investigation. However, despite the resident's refusal to have law enforcement notified, the facility did not report the allegation to local law enforcement as mandated by their policy, which requires immediate reporting of suspected crimes or alleged sexual abuse. Staff interviews confirmed that the occupational therapist, social worker, and PTA were all aware of the allegation and that an internal investigation was conducted. The corporate senior executive director stated that law enforcement should have been notified regardless of the resident's wishes, in accordance with the law. The facility's failure to notify law enforcement of the alleged abuse constituted a deficiency in following required reporting procedures for suspected abuse.
Failure to Discard Unused Liquid Medication Prior to Administration
Penalty
Summary
Staff failed to discard dispensed liquid medication that was not immediately administered to a resident, as observed during medication administration. Specifically, a medication technician prepared and signed out a dose of Lactulose for a resident with severe cognitive impairment, but did not administer it because the resident was asleep. Instead of discarding the medication, the technician returned the open medication cups to the medication cart, covered them with a larger cup, and locked the cart. Approximately 45 minutes later, the same medication was administered to the resident from the previously prepared cups. Interviews with staff confirmed that this practice was not in accordance with facility policy, which requires that medications not immediately administered should be discarded, and that staff should not pre-sign for medications before administration. The incident involved a resident with multiple significant diagnoses, including nonalcoholic steatohepatitis, end stage renal disease, chronic kidney disease, and cirrhosis of the liver.
Failure to Follow Hand Hygiene and Glove Use During Medication Administration
Penalty
Summary
A deficiency was identified when a Medication Administration Technician (Med Tech) failed to follow infection control practices during medication administration to a resident with multiple complex medical conditions, including end stage renal disease, diabetes, cirrhosis, and dementia. The resident was under Enhanced Barrier Precautions (EBP) for wounds, which required all staff to perform hand hygiene before entering and after leaving the room, and to wear gloves and gowns during high-touch care activities. During observation, the Med Tech entered the resident's room without performing hand hygiene and did not wear gloves. The Med Tech administered an oral liquid medication, holding the cup to the resident's mouth with bare hands, and used a tissue to dab the resident's mouth when medication dribbled out, again without gloves. After administering the medication, the Med Tech discarded the used tissue and medication cup in the trash, touching the trash can lid, and attempted to use the wall-mounted alcohol hand rub dispenser in the resident's room, which was found to be empty. The Med Tech then left the room and used a dispenser in another resident's room. Interviews with the Med Tech, a Registered Nurse, and the Director of Nursing confirmed that the expected protocol was not followed, as hand hygiene should have been performed before entering the room and gloves should have been worn due to the potential contact with bodily fluids.
Failure to Ensure Resident Was Free from Significant Medication Errors
Penalty
Summary
A significant medication error occurred when a resident with diagnoses including hemiplegia, anxiety, and hypertension was not administered his prescribed morning medications. The resident, who was cognitively intact, told the RN that he had already received his medication, leading the RN to instruct the medication technician not to administer the morning doses. The Medication Administration Record was not signed to indicate the medications were given, and the RN documented that the resident refused all morning medications without further investigation to confirm whether the medications had actually been taken. The resident's morning medications included several for hypertension, as well as others for various conditions. Later that day, the resident experienced a hypertensive crisis with a blood pressure reading of 217/211, reported chest tightness, and was transferred to the hospital. The only documented refusal for the entire month was on this day, and the resident later stated he had never refused his medications, though he could not recall the specific details of the incident. The Director of Nursing confirmed that the RN should have verified whether the medications were administered, which did not occur. The resident's hospital discharge summary indicated he did not receive three of his prescribed antihypertensive medications that morning.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with pressure injuries, leading to the deterioration of the resident's condition. The resident, who was at risk for pressure injuries, developed a stage 2 coccyx pressure injury, which was not thoroughly assessed or documented in a timely manner. The care plan was not updated with new offloading interventions, and the resident later developed a Deep Tissue Injury (DTI) on the right heel, which also lacked appropriate care plan updates and interventions. The facility's wound care process was inconsistent, with the Wound Nurse Practitioner unable to complete a weekly assessment, and the Assistant Director of Nursing failing to provide a comprehensive assessment of the wounds. The resident's coccyx pressure injury worsened to an unstageable stage, and the care plan still lacked necessary updates. Communication between the facility and hospice staff was unclear, leading to inadequate documentation and assessment of the resident's pressure injuries after being placed on hospice care. Throughout the resident's care, there were multiple instances where the care plan was not updated with necessary interventions, such as turning, repositioning, and the use of Prevalon boots, despite recommendations from the Wound Nurse Practitioner. The lack of thorough assessments and clear communication between facility and hospice staff contributed to the resident's declining condition, ultimately resulting in hospitalization and the development of additional wounds.
Inadequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure the safety of several residents, leading to multiple unwitnessed falls and inadequate supervision. One resident, with severe cognitive impairment and a high fall risk, sustained five unwitnessed falls, including one resulting in a left femur fracture. The facility did not conduct thorough root cause analyses for these falls, nor did they implement effective interventions to prevent future incidents. Despite the resident's known history of self-transferring and not using the call light, the care plan lacked specific supervision strategies, and the resident was often found unsupervised in their room. Another resident experienced two falls, one involving a shower chair collapse and another during a sit-to-stand transfer. The facility's investigation into these incidents was insufficient, as it did not include statements from the resident or a thorough analysis of the equipment involved. The fall investigations failed to determine the root causes, and there was no evidence that all shower chairs and slings were inspected for safety or that staff received adequate training on safe transfer techniques. Additionally, the facility did not ensure the safe storage of medications on one of the units reviewed. This oversight, combined with the lack of adequate supervision and investigation into falls, highlights significant deficiencies in the facility's ability to maintain a safe environment for its residents. The facility's failure to address these issues adequately resulted in ongoing risks to resident safety and well-being.
Inadequate Facility-Wide Assessment and Documentation
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment necessary for competent resident care during both routine operations and emergencies. The assessment lacked documentation of staffing ratios for different shifts, which is crucial for determining the appropriate level of care and staff required. Additionally, the role of the Director of Nursing (DON), who also serves as the Infection Preventionist (IP), was not adequately assessed in terms of time allocation for each responsibility. The facility's Water Management Committee was not included in the assessment, and potential infection risks such as COVID-19, influenza, and Legionella were not evaluated. During an interview, the Nursing Home Administrator (NHA) acknowledged that the facility's focus was not on the Facility Assessment at the time. The revised assessment provided later still did not address the initial deficiencies adequately, as it merely stated that the DON dedicates time to the Infection Preventionist Control Program (IPCP) as needed and that the Water Management Plan is part of the Emergency Preparedness Plan. The lack of a thorough assessment had the potential to affect all 43 residents in the facility.
Infection Control Deficiencies in Glucometer Use and Facility Management
Penalty
Summary
The facility failed to implement effective infection control measures, as observed in the handling of glucometers and laundry, and in the management of water systems. Two residents, R41 and R38, were tested for blood sugar using a shared glucometer that was not sanitized between uses. The Registered Nurse (RN) responsible for the testing did not clean the glucometer after use, and the facility lacked a policy for glucometer cleaning. Additionally, the RN was unable to locate sanitizing wipes, which are necessary for proper cleaning, indicating a gap in infection control practices. The facility also demonstrated deficiencies in the management of laundry and water systems. Laundry staff were observed delivering clothes without using covers for the clothing racks, which could lead to contamination. The Laundry Supervisor was unaware of the need for covers, highlighting a lack of training or policy enforcement. Furthermore, the facility's water management plan lacked documentation of control measures for preventing Legionella, such as regular cleaning of ice machines and monitoring of water heaters. The Maintenance Director could not provide adequate documentation to show that these measures were being implemented as planned. In addition, the facility did not maintain an updated list of staff fit-tested for N95 masks, which is crucial during an outbreak. The Infection Preventionist and Nurse Consultant were unable to provide a current list, relying instead on outdated records from 2021. The facility's infection surveillance and tracking were also inadequate, with inconsistent data and a lack of documentation to identify infection trends. The Infection Preventionist admitted to calculating infection rates incorrectly, which could hinder the facility's ability to implement effective preventative interventions.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by delayed call light responses and the absence of a designated charge nurse on certain shifts. Surveyors observed residents experiencing prolonged wait times for assistance, with one resident waiting over 28 minutes for help to use the bathroom. Another resident reported that their call light was turned off without receiving assistance, and they had to personally inform staff to receive help. These incidents highlight the facility's inability to ensure timely care and assistance for residents, impacting their physical and psychosocial well-being. During a Resident Council meeting, residents expressed concerns about inadequate staffing levels, which they felt led to long call light wait times. Some residents reported that CNAs were unresponsive or unwilling to assist them, citing that it was not their job or that they were not assigned to that particular resident. Additionally, residents expressed frustration with the use of floaters, who were not consistently available to provide care, further exacerbating delays in receiving assistance. These accounts underscore the residents' perception of being treated as tasks rather than individuals, contributing to their dissatisfaction with the care provided. The facility's staffing schedules for the past 30 days revealed a lack of designated charge nurses on multiple dates, which is a requirement for ensuring proper oversight and coordination of care. The Scheduler was unaware of the need to document charge nurses on the schedule and was unfamiliar with the Facility Assessment document, which should guide staffing levels. The Nursing Home Administrator acknowledged the staffing concerns and mentioned recent efforts to hire additional staff, but the facility did not provide any additional information or documentation to address the surveyor's findings.
Failure to Provide Transfer Notifications and Ombudsman Notification
Penalty
Summary
The facility failed to provide written notification of transfer to the hospital for six residents, as well as failing to notify the State Ombudsman. This deficiency was identified through interviews and record reviews conducted by the surveyor. The residents involved were transferred to the hospital due to changes in their medical conditions, but neither they nor their representatives received the required written notifications. Additionally, the facility did not send these notifications to the State Ombudsman, as mandated. The surveyor's investigation revealed a lack of clarity and accountability among the facility staff regarding who was responsible for issuing the transfer notifications. Interviews with Social Services, Referral Specialist, and the Nursing Home Administrator highlighted confusion and miscommunication about the roles and responsibilities related to the notification process. Social Services indicated that the Referral Specialist was responsible, while the Referral Specialist claimed that floor staff handled the notifications. The Nursing Home Administrator provided conflicting information, further complicating the issue. The residents affected by this deficiency had various medical conditions, including dementia, diabetes, chronic kidney disease, and heart failure. They were transferred to the hospital for conditions such as acute hepatic encephalopathy, severe sepsis, and encephalopathy. Despite the seriousness of their conditions, the facility failed to provide the necessary documentation and communication to the residents, their representatives, and the State Ombudsman, as required by regulations.
Failure to Maintain Bowel Continence in Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R22, who was initially continent of bowel upon admission, received appropriate services and assistance to maintain continence. R22 experienced a decline in bowel continence after admission, but the facility did not conduct a comprehensive assessment of this decline, nor did they implement any new interventions to address the issue. The facility's policy and procedure for bowel and bladder management require staff to assess and document bowel movements, but there was no evidence that R22's bowel movements were being documented or monitored. R22 was admitted with a history of being continent of bowel, but subsequent evaluations indicated a change to always incontinent. Despite this change, there was no evidence that the facility recognized the decline in R22's bowel continence or completed a comprehensive assessment. Additionally, there was no evidence that a toileting program was implemented to maintain bowel continence, as required by the facility's policy. The Director of Nursing (DON) acknowledged that the recording of bowel movements was not activated in the Point of Care (POC) system, which resulted in a lack of records to determine when or why R22 became incontinent. The surveyor noted the absence of documentation and monitoring of R22's bowel movements and continence, as well as the lack of a comprehensive assessment or new interventions following the decline in continence.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to self-administer medications before staff left medications at the bedside. The resident, who is cognitively intact with a BIMS score of 15, was observed with multiple medications in a cup on her bedside table without an order or assessment for self-administration. The resident's medical history includes End Stage Renal Disease, Diabetes, Cerebrovascular disease, dependence on dialysis, heart failure, dementia, and Transient ischemic attack. During an interview, the resident confirmed that some staff leave medications in her room, depending on which nurse is working. The surveyor noted that there was no documentation of an order or assessment for the resident to self-administer medications. The Nursing Home Administrator and Director of Nursing were informed of these findings, but no additional information was provided.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident, identified as R7, who was admitted with diagnoses including urinary tract infection, Multiple Sclerosis, and Quadriplegia. R7 was cognitively intact and relied on a call light system to request assistance. During an observation, the surveyor found R7's call light out of reach, which prevented the resident from calling for help. R7 expressed thirst and needed assistance to get water, but staff were not immediately available. When a CNA eventually arrived, they were unfamiliar with how to properly place the call light within R7's reach, requiring R7 to instruct the CNA on how to secure it properly. Interviews with the Director of Nursing and the Nursing Home Administrator revealed that staff should have been trained to ensure call lights are within reach of residents, including those with special needs like R7, who uses a pressure plate with their head to activate the call light. The CNA involved was typically assigned to the assisted living side of the facility and was not adequately prepared to handle the specific needs of R7. The deficiency was acknowledged by the facility's administration, who confirmed that all staff should be aware of the proper placement and use of call lights, regardless of their usual work area.
Resident's Code Status Not Clearly Indicated in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's code status was clearly indicated in their medical record, leading to a deficiency in honoring the resident's right to formulate an advance directive. The resident, who was admitted with multiple diagnoses including Diabetes Mellitus Type 2, Chronic Kidney Disease, and Atherosclerotic Heart Disease, had a BIMS score indicating no cognitive impairment. Despite expressing and signing a wish for a Do-Not-Resuscitate (DNR) status, the resident's code status was not clearly documented in the medical record, and there was no physician's order for the code status. During the survey, it was discovered that the resident's code status was not easily accessible or clearly indicated on the Point Click Care (PCC) dashboard or the Medication Administration Record (MAR). A Licensed Practical Nurse (LPN) was unable to verify the resident's code status during an interview, and the Director of Nursing (DON) confirmed that the code status was not entered correctly in the system. The Nursing Home Administrator (NHA) acknowledged the issue and noted that the facility was in the process of ensuring that all residents' code statuses were clearly listed. The surveyor noted that although the resident had signed a document expressing a DNR wish, the facility considered the resident to be a full code because the signed state DNR form had not been received. This discrepancy led to confusion and a lack of clarity regarding the resident's code status in the event of an emergency. The facility was advised of the concern that the resident's code status was not clearly indicated, despite the resident's expressed wishes for a DNR status.
Confidentiality Breach of Residents' Medical Records
Penalty
Summary
The facility failed to ensure the confidentiality of residents' personal and medical records, as observed during a survey. Two residents, R38 and R41, were involved in incidents where their Medication Administration Records (MAR) and medication cards were left unattended and in open view of others. Specifically, R38's medication cards and MAR were left on top of the medication cart while the Registered Nurse (RN) was away from the cart, and the computer screen displaying R38's MAR was left open. Similarly, R41's MAR was left visible on the computer screen while the RN was performing a blood sugar test in the resident's room. The facility's policy on medication administration requires that the medication cart be kept closed and locked when not in use, and that all resident information, such as MARs, be kept private by closing the MAR book or covering the MAR sheet or computer screen. However, these protocols were not followed during the medication pass observed by the surveyor. The Nursing Home Administrator was informed of these concerns, but no additional information was provided in response to the surveyor's findings.
Failure to Complete Level 2 PASARR Assessments
Penalty
Summary
The facility failed to complete a Level 2 Pre-Admission Screening and Resident Review (PASARR) assessment for two residents, R9 and R38, who were reviewed for Level 2 PASARR Screens. R9, who was admitted with diagnoses including Schizoaffective disorder, Bipolar disorder, intellectual disabilities, dementia, and Altered Mental Status, did not have a completed Level 2 PASARR screen despite having severe cognitive impairment as indicated by a BIMS score of 0. The medical record for R9 showed a Level I PASARR was completed, but there was no documentation of a Level 2 PASARR. Similarly, R38, who was admitted with Down Syndrome and generalized muscle weakness, also lacked a completed Level 2 PASARR screen. R38's MDS indicated a BIMS score of 14, showing cognitive intactness. The Referral Specialist responsible for PASARR screenings stated that a Level 2 PASARR is completed only upon receiving an email notification, which was not received for R38. The Nursing Home Administrator was informed of the missing Level 2 PASARRs for both residents, but no additional information was provided.
Failure to Complete Neurological Checks After Unwitnessed Falls
Penalty
Summary
The facility failed to complete neurological checks in accordance with its policy and procedure for two residents who experienced unwitnessed falls. The policy, revised on 6/13/23, requires licensed nurses to monitor and record neurological status at specified intervals following an unwitnessed fall. However, for one resident, neurological checks were not initiated for three unwitnessed falls and were not fully completed for two additional falls. This resident had severe cognitive impairment and was identified as high risk for falls. Another resident, who had moderate cognitive impairment and required substantial assistance for mobility, also experienced an unwitnessed fall. Despite the initiation of neuro-checks as per the progress note, the facility could not provide documentation that these checks were completed. Interviews with staff, including the CNA, RN, and ADON, revealed that neuro-checks should be documented on paper and collected by the ADON or DON, but the documentation was not found. The Director of Nursing and Nursing Home Administrator were informed of the lack of documentation for the neuro-checks following the unwitnessed falls. The facility did not provide further information or documentation to explain why the neurological checks were not completed as per the policy for the residents involved.
Deficiency in Dialysis Care for Resident
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident, identified as R16, who required such services. R16, a resident with End Stage Renal Disease (ESRD) and other comorbidities, was admitted to the facility needing dialysis but did not have physician orders regarding the care and treatment of dialysis. The facility did not monitor R16's dialysis access site daily, and there was a lack of consistent communication between the facility and the dialysis center. Additionally, R16 did not have a comprehensive care plan that addressed dialysis, including the location of the access site or how the facility staff would provide care and treatment to the site. Observations and interviews revealed that the facility's staff, including RN-O, did not document monitoring of R16's dialysis site in the medical records. RN-O stated that the facility prepared medical records for R16 to take to dialysis appointments, but R16 sometimes returned without communication papers from the dialysis center. The Director of Nursing (DON)-B acknowledged that residents receiving dialysis should have a dialysis care plan, monitoring, and documentation of the dialysis site, as well as communication with the dialysis center. However, the facility assumed dialysis occurred without events if the resident returned without paperwork or a phone call from the dialysis center. The facility's hemodialysis policy, last reviewed in 2018, required coordination and communication between the Skilled Nursing Facility (SNF) staff and the dialysis staff. The policy outlined the need for an individual care plan, identification of risk factors, monitoring of the dialysis site, and communication with the dialysis team. Despite these requirements, the facility did not adhere to its policy, resulting in a deficiency in providing appropriate dialysis care for R16.
Failure to Regularly Assess Bed Rail Use and Risks
Penalty
Summary
The facility failed to regularly assess the risk of entrapment and review the risks and benefits of bed rail use for a resident, identified as R5, who was observed with a half side rail/grab bar on the right side of the bed. R5, who is dependent on staff for mobility, had not undergone a completed side rail risk assessment since September 18, 2023, and was not included in the monthly safety audits of side rails conducted by the maintenance department. The facility lacked a siderail policy, and there was no evidence of a side rail assessment and risk screen being completed after R5's condition changed, making them completely dependent on staff for mobility. R5 was admitted to the facility with multiple diagnoses, including chronic kidney disease, type 2 diabetes, dementia, stroke history, encephalopathy, and adult failure to thrive. The resident's significant change Minimum Data Set assessment documented severe cognitive impairment and complete dependence for bed mobility, hygiene care, and transfers. Despite this, the facility's staff, including a CNA and RN, indicated that R5 did not use the siderail, as R5 was dependent and unable to use it. Interviews with facility staff, including the Assistant Director of Nursing, Physical Therapist, and Director of Nursing, revealed inconsistencies in the process and frequency of completing side rail assessments and risk screens. The assessments were supposed to be done quarterly or with a change in condition, but R5's assessment was missed after their condition changed. Additionally, the maintenance department did not include R5 in the monthly audits for side rail safety, and the facility's leadership acknowledged the oversight but did not provide further information on why the assessments were not regularly conducted.
Failure to Provide Adequate Social Services for Resident Transfer
Penalty
Summary
The facility failed to provide medically related social services to a resident, R10, which resulted in an increased level of depression, anxiety, and uncertainty regarding their transfer or discharge. R10, who was admitted with a diagnosis of depression and anxiety disorder, expressed a desire to leave the facility and transfer to another location. However, the facility's Social Services did not communicate timely with R10 or their family, nor did they follow through with R10's expressed wishes until the issue was brought to their attention by a surveyor. R10's care plan included interventions for mood problems related to depression and anxiety, but there was a lack of documentation and follow-up from the facility's Life Coach-Q regarding R10's transfer request. Despite R10's repeated attempts to communicate with Life Coach-Q, there was no documented progress or updates provided to R10 about the transfer status. The Life Coach-Q had not documented any progress notes after an initial follow-up, and there was a significant delay in addressing R10's concerns, which contributed to R10's emotional distress. Interviews with R10 revealed feelings of being uninvolved in their care planning and dissatisfaction with the facility's staff, particularly with Life Coach-Q, who was responsible for coordinating transfers. The lack of communication and follow-up from the facility staff led to R10's increased anxiety and depression, as they felt their needs were not being met and their requests were not being taken seriously. The facility's failure to provide adequate social services and timely communication contributed to R10's deteriorating mental and psychosocial well-being.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 8%. During a medication administration observation, a Registered Nurse (RN) prepared and administered medications to a resident, R38, but did not adhere to the prescribed orders. The RN initially prepared a set of medications, including Vitamin B1, Acetaminophen, Atorvastatin, Potassium Chloride, Vitamin B12, Aspirin, Furosemide, Metformin, and Fluticasone spray. However, the RN realized that Potassium Chloride 20 meq and Atorvastatin were missing and left the medication cart to retrieve them from the contingency supply. Upon returning, the RN added Potassium Chloride ER 20 meq and two Atorvastatin 10 mg tablets to the medication cup. The surveyor verified the number of tablets and observed the RN administering the medications to the resident. A review of the resident's Medication Administration Record (MAR) revealed discrepancies: the resident was supposed to receive 0.5 tablet (20 mg) of Furosemide, but a full 40 mg tablet was administered, and an additional dose of Atorvastatin was given. The Nursing Home Administrator was informed of these observations and the medication error rate, but no further information was provided.
Failure to Date Opened Insulin Vials and Pens
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically regarding the dating of insulin vials and pens when opened. During observations, the surveyor found that insulin vials and pens for three residents were opened and used but not dated when opened, which is a requirement according to the facility's policy and procedure. The policy states that the date opened must be recorded on multidose vials, and the shortened expiration date for opened vials is 28 days unless specified otherwise by the manufacturer. The surveyor observed these deficiencies in both the medication cart and the medication room refrigerator. Insulin vials and pens belonging to three residents were found without the required dating, indicating a lapse in adherence to the facility's policy. The RN and DON were informed of these findings, but no additional information was provided to address the concerns. This oversight in labeling could potentially lead to the use of expired medications, although the report does not specify any adverse outcomes resulting from this deficiency.
Failure in Hospice Collaboration and Wound Care Management
Penalty
Summary
The facility failed to ensure proper collaboration and communication with hospice services for a resident receiving hospice care, leading to a lack of continuity in wound care management. The resident, who had a history of chronic kidney disease, type 2 diabetes, dementia, and other conditions, was admitted to the facility with unstageable pressure injuries and was later placed on hospice care. Despite the facility's policy on pressure injury prevention and management, there was a breakdown in communication between the facility and hospice staff regarding the responsibility for assessing and treating the resident's pressure injuries. The hospice nurse, RN-J, was not aware that they were solely responsible for the resident's wound care, resulting in incomplete assessments and documentation of the resident's pressure injuries. From the time the resident was readmitted to the facility on hospice care, the coccyx pressure injury was not measured, and comprehensive assessments were not documented by either facility or hospice staff. Additionally, a new wound developed on the resident's right lateral leg, but it was not thoroughly assessed or measured until several days later, and no root cause analysis was conducted. The lack of clear communication and documentation led to inadequate monitoring of the resident's wounds, as evidenced by the absence of thorough assessments and measurements in the electronic medical record. The facility's Director of Nursing and the hospice nurse had a conversation about the wound care plan, but it was not effectively communicated or documented, resulting in missed assessments and a lack of updated interventions in the care plan. This deficiency highlights the need for clear communication and documentation between facility and hospice staff to ensure continuity of care for residents receiving hospice services.
Failure to Monitor Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to maintain an antibiotic stewardship program for a resident receiving prophylactic antibiotic treatment for clostridium difficile (c-diff). The resident began receiving vancomycin prophylactically in April 2023, but the facility's Infection Preventionist (IP) and Director of Nursing (DON) were unaware of this treatment. The antibiotic use was not monitored or reviewed during infection prevention and control surveillance, nor was it reported to the facility's Quality Assurance Performance Improvement (QAPI) team. The facility's policy on infection control, reviewed in September 2023, outlines the need for monitoring antibiotic usage patterns through the QAPI process. However, the policy did not specify that tracking should include antibiotics used prophylactically. During the survey, the IP/DON acknowledged the oversight and stated that the prophylactic use of antibiotics was not being tracked as part of infection control. The Nursing Home Administrator also confirmed a lack of awareness regarding which residents were on antibiotics, indicating a gap in the facility's antibiotic stewardship program.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the State Survey Agency (SA) as required by their policy and federal and state law. The incident involved a resident with multiple medical diagnoses, including psychosis and intellectual disabilities, who was reportedly slapped by a man in the dining room. However, upon further inquiry by the staff, the resident denied being slapped or touched, stating instead that a male kitchen staff member waved at her and said he couldn't talk, which upset her. Despite this, the facility's policy mandates that all allegations of abuse, regardless of the outcome of initial inquiries, must be reported to the SA immediately or within two hours if the allegation involves abuse. The facility's policy, titled 'Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program,' clearly outlines the requirement for immediate reporting of abuse allegations to the SA and other relevant authorities. However, a review of the facility's incident reports revealed no documentation of the incident involving the resident, and the Administrator confirmed that the incident was not reported. The Nurse Consultant also confirmed that the expectation was for all allegations of abuse to be reported, highlighting a failure in the facility's adherence to its own policies and regulatory requirements.
Failure to Investigate Allegation of Physical Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of physical abuse involving a resident, identified as R6, who was part of a sample of 16 residents reviewed for abuse. The incident in question occurred when a CNA reported that a man slapped the resident in the dining room during supper. Upon questioning, the resident denied being slapped or touched, stating instead that a male kitchen staff member waved at her and said he couldn't talk, which upset her. Despite this, the facility did not initiate a formal investigation into the allegation of physical abuse. The facility's policy on abuse requires immediate investigation of any reported or suspected incidents of abuse, including gathering statements from involved parties and witnesses, assessing the resident's behavior and environment, and ensuring the resident's protection. However, interviews with the Administrator and Nurse Consultant confirmed that no investigation was conducted regarding the alleged slapping incident. This oversight had the potential to compromise the protection of residents against abuse, as the facility did not adhere to its own policy of conducting a root cause investigation and analysis.
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 746 citations issued within 25 miles in the last 12 months — including the 17 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 Milwaukee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Luther Manor | 1.2 mi | ★★★★★ | 19 | 0 |
| Lutheran Home | 2 mi | ★★★★★ | 0 | 0 |
| Congregational Home, Inc. | 3 mi | ★★★★★ | 0 | 0 |
| St Camillus Health Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Milwaukee Health And Rehab | 4.7 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.