Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sun Prairie Senior Living during CMS and state inspections, most recent first.
Unsafe food storage, temperature control, and sanitation practices were observed in the kitchen and resident snack area. Surveyors found cereal on the pantry floor, an uncovered dry pasta container, milk on room trays at 69 and 71 degrees F, sanitizer testing at 500 ppm with inaccurate log entries, food employees working without beard restraints, and a broken snack refrigerator with melted Jell-O and unfrozen ice cream.
A resident with dementia, progressive supranuclear ophthalmoplegia, type 2 DM, and oropharyngeal dysphagia, who was cognitively intact per BIMS, had concerns raised by an activated POA about the resident not being gotten out of bed for activities and having a broken wheelchair. The POA reported unreturned calls and lack of follow-up from the NHA. Facility grievance records showed only one documented concern related to the resident’s activities and wheelchair, with no entry for an earlier similar concern, and the NHA was unable to confirm whether an investigation into why the resident was not up for activities or whether interviews with the resident, staff, or POA occurred. The NHA also acknowledged that no written resolution was provided to the resident’s representative, despite facility policy requiring that grievance resolutions be documented and shared with the resident or representative.
Two residents who required assistance with ADLs did not receive scheduled showers or adequate grooming. One cognitively intact resident with ESRD, CHF, and diabetes was care planned and scheduled for twice-weekly showers but, per documentation and interview, had only one shower since admission. Another resident with prostate CA, dementia, anxiety, and significant hand deformities was also care planned and scheduled for twice-weekly showers, yet records showed no showers since admission; this resident had noticeable facial hair, reported disliking it, and was unable to shave independently. The DON confirmed the lack of documented showers and was unsure how often residents should be shaved, while a CNA reported shaving is part of daily ADLs but had not shaved the resident that morning and had not noticed the long whiskers.
A facility failed to maintain a safe, clean, comfortable, and homelike environment for two cognitively intact residents. One resident reported a soiled room divider curtain and a carpet that had not been vacuumed, with surveyors observing stains and debris over multiple days. Another resident reported a leaking toilet with water pooling on the bathroom floor, and surveyors observed a large puddle while staff interviews showed the issue had been known for days.
Failure to Report Alleged Abuse to State Agency: A cognitively intact resident and family member reported that a CNA made a demeaning comment to the resident during the night. Staff discussed the concern internally, but the NHA confirmed the allegation was not reported to the State Survey Agency. Interviews showed the DSS, LPN, and admissions staff were aware of the concern, while the NHA was not fully informed of the specific allegation.
Incomplete Investigation of Resident-to-Resident Abuse Allegation: A resident-to-resident abuse allegation involved one resident striking another resident on the head in the dining room. Staff separated the residents and two staff witnesses described the contact differently, but the facility did not document interviews with other residents or responsible parties to determine the scope of the concern. The NHA stated only the involved resident was interviewed and acknowledged she did not know other residents should have been interviewed.
A resident’s MDS did not accurately code her pressure injuries. Hospice and the NP documented a large coccyx wound with undermining and necrotic areas on both buttocks, and the NP identified unstageable ulcers of the coccyx and left buttock and a stage 3 ulcer of the right buttock. Despite this, the MDS marked unhealed PI/injury as “NO,” and an RN confirmed that MDSs should be completed accurately and should document the resident’s PIs.
PASRR screening was not completed for a resident reviewed for PASRR compliance. The resident had diagnoses including Parkinson’s disease, depression, and insomnia due to another mental disorder, and the NHA could not locate a PASRR on file. The DON stated that if PASRR was in the facility policy, it should have been completed.
The facility failed to keep a resident area free of hazards when a motorized wheelchair battery was observed charging in a conference room used by residents, and the NHA stated there was no policy for charging batteries or motorized assistive devices. The facility also failed to provide ordered meal supervision for a resident with dementia, dysphasia, and swallowing concerns; staff dropped off the breakfast tray and left the room, while CNAs reported only brief checks or being unaware of the supervision requirement.
A resident with OSA and other serious diagnoses was admitted with hospital orders for BiPAP use all night and when napping, but the order was never transcribed and the resident did not receive BiPAP at the facility. Surveyors observed the BiPAP machine sitting on the floor, and staff gave conflicting accounts about whether the resident used or refused it; the DON and CSRN also did not clearly identify the order during interview.
A resident receiving dialysis with a CVC access site had no emergency plan in the care plan, physician orders, or facility dialysis policies for bleeding from the access site. Staff responses varied during interview: a CNA would get the nurse, an LPN would call the provider and try to stop the bleeding, while the DON expected staff to apply pressure, call for help, dial 911, and send the resident to the hospital.
Expired oxycodone was found in a medication cart and had been given to a resident after the printed expiration date. The resident had diagnoses including encephalopathy, left hip pain, and anxiety, and had an order for oxycodone PRN. RN and DON staff confirmed the medication should not have remained in circulation, and pharmacy review had missed the expired tablets.
Expired lorazepam and oxycodone were found in a medication cart for two residents during surveyor observation. RN confirmed both medications had expired and should not have been in circulation, while the DON and CSRN stated pharmacy audits medications and nursing staff perform random checks, but the expired meds had been missed.
Infection control breaches occurred during wound care and contact precautions. An IP/WN failed to perform hand hygiene and change gloves after cleansing a resident’s wound before moving to clean tasks and applying a dressing. In a separate event, an LPN removed a resident’s drinking cup from a room where contact precautions were in place, had it refilled in the hallway, and returned it to the room; the resident had ESBL infection and was on contact precautions.
A resident with dementia, chronic pain, anxiety, and diabetes who required extensive assistance with ADLs did not have a comprehensive care plan with specific approaches for staff to follow. Staff interviews confirmed the absence of documented interventions in the care plan and resident profile, despite facility policy requiring such documentation.
Two residents requiring assistance of two staff members for transfers were inadequately assisted by a single CNA, contrary to their care plans. One resident, with chronic heart failure and knee replacements, and another with heart disease and dementia, were transferred solo by the CNA, despite needing two-person assistance. The DON confirmed the requirement for two staff members during transfers.
The facility did not have an RN on duty for 8 consecutive hours on a specific day, as required. A review of staff schedules showed no RN was present for any shift on that day, and the DON confirmed the absence was due to a call-in. This affected all 33 residents in the facility.
The facility failed to maintain food safety and sanitation standards, affecting all residents. Staff were observed preparing food without proper hair restraints, and the facility did not record dishwasher temperature checks. Expired food items and dented cans were found in circulation, and unlabeled food was observed, indicating non-compliance with FDA and facility policies.
The facility failed to implement an effective infection prevention and control program during a COVID-19 outbreak, with lapses in contact tracing, testing, and PPE use. Staff did not adhere to proper infection control practices, such as wearing PPE and performing hand hygiene. A resident's urinary catheter was improperly managed, potentially contributing to infections. These deficiencies could affect the entire resident census.
A resident with moderate cognitive impairment was taken to breakfast in her pajamas against her expressed wishes, compromising her dignity. The CNAs prioritized other tasks and did not consult the resident, leading to feelings of embarrassment and a violation of resident rights. Staff acknowledged the dignity issue, recognizing the importance of respecting resident preferences.
A resident on hospice care expressed concerns about the cleanliness of her room, which was confirmed by a surveyor's observations of dust and debris. The Environmental Services staff cited insufficient housekeeping staff, and there was no system to track room cleaning. The Nursing Home Administrator acknowledged the expectation for daily cleaning but admitted there was no verification system in place.
A resident with a Stage III pressure ulcer did not receive necessary care as they spent five hours in a wheelchair without a pressure-relieving cushion. Additionally, an air mattress was used without staff knowledge of proper inflation, as there were no instructions or education provided. The DON confirmed that the mattress would not be effective if not properly inflated.
A resident at moderate risk for falls experienced multiple falls due to inadequate supervision and delayed interventions. The facility failed to document falls, update medical personnel, or implement individualized interventions. Despite knowing the resident's preferences for sleeping in a recliner with lights and TV on, the facility did not incorporate these into the care plan, leading to repeated falls while waiting for a scoop mattress.
A resident with a right humerus fracture experienced inadequate pain management due to the facility's failure to obtain prescribed narcotics and address the resident's refusal of uncoated acetaminophen. The care plan lacked specific pain tolerance levels and non-pharmacological interventions. Staff did not communicate effectively to resolve the missing prescription or the resident's medication preferences, resulting in ongoing pain and distress.
A LTC facility experienced a 16% medication error rate during a medication pass task, affecting three residents. Errors included late administration of Tylenol and vitamins, and improper timing of insulin administration relative to meals. The facility's policy and best nursing practices were not followed, as confirmed by the DON and CRN.
A resident who initially refused the influenza vaccine upon admission was not offered the vaccine again during the current flu season, contrary to the facility's policy. The resident's medical record lacked documentation of subsequent offers or education about the vaccine, as confirmed by the CRN and DON during an interview.
Unsafe Food Storage, Temperature Control, and Sanitation Practices
Penalty
Summary
The facility did not maintain a safe and sanitary environment for food storage, preparation, distribution, and service. During an initial kitchen tour, the surveyor observed cereal spilled on the pantry floor and a clear bin of dry pasta with the lid uncovered. The facility was unable to provide a food safety policy when requested. The report states that the issue had the potential to affect all 34 residents who resided in the facility. The surveyor also observed room trays being prepared for lunch with beverages covered in plastic wrap, but milk temperatures on trays were found to be out of range. One glass of milk measured 69 degrees F and another measured 71 degrees F. The Director of Food Services stated the drinks had been poured too far in advance and that beverages should be cold held until they go out. The surveyor also noted that staff were not taking beverage temperatures along with tray temperatures before the trays were sent out. The sanitizing solution used in the kitchen was also found to be outside the expected range. The Director of Food Services demonstrated testing the solution and it measured 500 ppm, which he acknowledged was high. The surveyor reviewed the facility log and found it recorded 175 ppm each day, but the Director of Food Services stated that the recorded number was actually water temperature, not sanitizer test results. In addition, the surveyor observed the Director of Food Services and another food employee working with resident food without beard restraints in place, despite the facility policy stating facial hair restraints are required in food production areas. The surveyor also inspected a refrigerator in the conference room labeled for resident snacks and found several packs of melted Jell-O, a warm refrigerator interior, a foul odor, and ice cream cups in the freezer that appeared unfrozen. Food service leadership stated the refrigerator had been broken for weeks and that maintenance had been told about it, while plant services stated no work order had been submitted until the issue was brought up during the survey.
Failure to Properly Document, Investigate, and Communicate Grievance Resolution
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to make prompt efforts to document, investigate, and resolve a resident’s and representative’s concerns, including failure to provide a written resolution. The resident, who was admitted with dementia, progressive supranuclear ophthalmoplegia, type 2 diabetes mellitus, and oropharyngeal dysphagia, had a BIMS score of 15/15, indicating intact cognition. The resident’s activated power of attorney (APOA) reported concerns to the Nursing Home Administrator (NHA) that the resident was not being gotten out of bed for activities on two Sundays in December and that the resident’s wheelchair was broken. The APOA stated that they left messages for the NHA that were not returned and that concerns about the resident not getting out of bed on one of those Sundays were not addressed through a documented grievance. When surveyors requested grievances related to the resident and the APOA’s concerns, the NHA produced a grievance spreadsheet for December that contained one entry for the resident dated late December, documenting that the daughter was upset the resident was not up for activities and that staff noted a broken wheelchair. The spreadsheet showed that hospice was contacted to evaluate and replace the wheelchair and that the concern was marked as satisfactorily resolved, with a note about working on establishing a care conference date. There was no grievance documented for the earlier Sunday in December when the APOA had also raised concerns. In an interview, the NHA described the facility’s process for entering concerns into an online or paper system but was unsure whether an investigation had been conducted into why the resident was not gotten up for activities, whether an alternate wheelchair could have been provided, whether the resident or staff were interviewed, or whether the daughter was contacted regarding her concerns. The NHA also confirmed that no written resolution was provided to the resident’s APOA, contrary to the facility’s policy requiring that resolutions be documented and shared verbally or in writing with the resident or representative.
Failure to Provide Scheduled Showers and Grooming Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who are unable to perform activities of daily living (ADLs) received necessary services to maintain personal hygiene, including bathing and grooming. The facility did not have an ADL policy, and documentation and interviews showed that two cognitively impaired or physically limited residents did not receive showers as care planned. One resident (R4), admitted with end stage renal disease, congestive heart failure, and type 2 diabetes mellitus, had an MDS indicating cognitive intactness (BIMS 15/15) and a need for substantial/maximal assistance with showering. The care plan required showers twice weekly and as needed, with a scheduled shower on the Friday AM shift, yet point-of-care records showed only one shower provided since admission. In an interview, this resident reported having only one shower since admission. Another resident (R41), admitted with prostate cancer, dementia, and anxiety, and with significant hand deformities (missing three fingers on the left hand and only partial thumb and 5th digit), also had a care plan calling for showers twice weekly and as needed, with a scheduled shower on the Saturday PM shift. Point-of-care documentation showed no showers since admission. During an interview, the surveyor observed 1/4–1/2 inch facial hair, and the resident stated they believed they had only one shower, did not like the facial hair, could not shave themselves, and that no one was shaving them. The DON confirmed that documentation reflected only one shower for R4 and none for R41 and was unsure how often residents should be shaved. A CNA stated residents are shaved anytime they ask or daily as part of ADLs but did not know when R41 was last shaved and acknowledged not shaving the resident that morning, despite having gotten them up and not noticing the long whiskers.
Soiled Room Conditions and Unrepaired Toilet Leak
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment for two residents. One resident, admitted with end stage renal disease, congestive heart failure, and type 2 diabetes mellitus, was cognitively intact with a BIMS score of 15. During observation and interview, the resident reported that the room divider curtain was soiled and that the carpet had not been vacuumed. Surveyor observations noted brownish-black spots on the curtain and debris, including smashed popcorn, on the carpet over multiple days, and the resident stated the popcorn had been there for a couple of days. Housekeeping staff stated that resident rooms are vacuumed every day and that a soiled room divider curtain would need to be taken down by maintenance to be washed. The housekeeper also observed that the curtain had something on it and said it should be replaced. The Nursing Home Administrator acknowledged that resident rooms should be vacuumed daily, agreed that the curtain appeared soiled, and stated that the concerns were not promoting a homelike environment. A second resident, admitted with spondylosis with myelopathy, dizziness and giddiness, and rheumatoid arthritis, was also cognitively intact with a BIMS score of 15. The resident reported that the toilet in the bathroom had been leaking for days and that water puddled on the floor near the toilet each night. Surveyor observation confirmed a large puddle of water around the front of the toilet, and staff interviews showed the issue had been known to aides, nursing staff, and maintenance before it was fully resolved. The resident stated that the toilet had remained an ongoing issue for nine days.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an alleged violation involving abuse was reported immediately to the administrator and to the State Survey Agency in accordance with policy and state reporting requirements for 1 of 16 residents reviewed, R43. R43 was admitted on 2/20/26 and had an MDS BIMS score of 14, indicating the resident was cognitively intact. R43 and FM G reported that a CNA told R43, "You're trouble. When I speak, you don't speak." R43 stated the comment occurred around 3:00 AM two nights before the survey interview and said the statement made the resident feel unable to speak up and explain needs. FM G reported the allegation to DSS E earlier that day. Survey interviews showed the concern was discussed among staff, but the NHA stated he was unaware of the specific comment reported by R43 and FM G and confirmed the concern was not reported to the State Agency. DSS E stated she was aware of the concern and that an investigation had been started by LPN D, who said she had heard about a staff concern third hand and contacted the two staff members scheduled to see if they had spoken with the resident. AC F stated she was present when FM G reported the concern and believed it should be escalated, and she gave the information to LPN D. The facility policy stated alleged abuse must be reported immediately, but not later than 2 hours if abuse or serious bodily injury is involved, or not later than 24 hours if not.
Incomplete Investigation of Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility did not ensure there was evidence that an alleged resident-to-resident abuse incident involving two residents was thoroughly investigated. The report states that one resident made contact with the top of another resident’s head in the dining room before the evening meal, and staff immediately separated the residents. The resident who was touched had diagnoses including stroke and hemiparesis, and denied pain, injury, or distress after the incident. The other resident involved had diagnoses including stroke, chronic encephalopathy, cerebral ischemia, unspecified convulsions, and major depressive disorder, with psychiatric documentation noting poor judgment, poor insight, poor impulse control, flight of ideas, and tangential thought process. The facility documented that staff were present during the incident and that two staff members witnessed it. One witness described the event as the resident standing over the other resident and popping him on the head, while another witness described the resident coming up behind the other resident and tapping or smacking him on the top of the head with an open hand. The investigation record also states that the residents were separated, assessments were completed, and the incident was reported. However, the report indicates there was no documentation that other residents or responsible parties were interviewed to determine whether anyone else may have been affected. During surveyor interviews, the nursing home administrator stated that no other residents were interviewed to determine the scope of the concern and said she only interviewed the resident who was touched. She also stated she was not aware that other residents should have been interviewed to determine the scope of the concern. The report concludes that the investigation was not thorough because the facility did not interview other residents to determine the scope of the issue.
MDS Did Not Accurately Reflect Resident’s Pressure Injuries
Penalty
Summary
The facility failed to ensure that a resident’s assessment accurately reflected the resident’s status. For 1 of 16 residents reviewed, the Minimum Data Set (MDS) for R5 did not correctly code the resident’s pressure injuries. The facility did not have a policy and procedure for MDS accuracy and instead followed the Resident Assessment Instrument (RAI) manual, which requires that the assessment accurately reflects the resident’s status. The record showed that hospice identified and measured R5’s pressure injuries as a 9.0 x 17.3 cm open area at the coccyx with undermining from 7-9 o’clock and a depth of 2.1 cm, with necrotic areas on both buttocks and slough present to the coccyx area. The nurse practitioner documented decubitus ulcers of the coccyx and left buttock as unstageable and the right buttock as stage 3. R5’s physician orders also addressed bilateral buttocks/coccyx wound care. However, R5’s MDS dated [DATE] marked Section M, M0210 Unhealed Pressure Ulcer/Injury as “NO.” During interview, the Clinical Support RN stated that MDSs should be completed accurately and that R5’s MDS should document her pressure injuries.
PASRR Screening Not Completed for a Resident
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for 1 of 5 residents reviewed, R43. The facility’s Wisconsin Department of Health Services Forward Health Update policy stated that federal regulations require screening of all individuals seeking admission to a Medicaid-enrolled nursing facility to determine the presence of a major mental illness and/or developmental disability, and that nursing facilities meet this requirement by conducting a preadmission Level I screen for anyone meeting the definition of a new admission. R43 was admitted to the facility, was on hospital leave from 2/21/26 to 3/20/26, and was readmitted to the facility with diagnoses including Parkinson’s disease, depression, and insomnia due to another mental disorder. When the surveyor requested PASRR documentation, the NHA stated on 4/1/26 at 1:00 PM that they were unable to locate a PASRR on file for R43. At 1:30 PM, the DON stated that if PASRR was in the facility’s policy, it should have been completed.
Unsafe Battery Charging and Failure to Supervise Meals
Penalty
Summary
The facility did not ensure that the resident environment remained as free of accident hazards as possible when R27’s motorized wheelchair battery was observed charging in the conference room. The Nursing Home Administrator stated that the wheelchair should be charged in the conference room, but also stated the facility did not have a policy regarding charging batteries. The conference room was observed not to have a fire safe door, and the administrator stated she was unsure whether the battery needed to be charged behind a fire-proof door. The administrator also stated that batteries should not be charged in resident areas because of possible explosion and harmful fumes, and identified the room as the conference room. The conference room was used by residents, as shown by the facility’s March activity calendar listing Book Club, Absentee Voting, and Bible Sharing in that room. During the survey, R27 entered the conference room and stated that his family member would be bringing him dinner there that night and that they were going to use the conference room, further showing resident use of the area where the battery was charging. The facility did not have a policy for charging electric wheelchair batteries or for motorized assistive devices. The facility also did not provide ordered meal supervision for R26. R26 had diagnoses including dementia, progressive supranuclear ophthalmoplegia, type 2 diabetes mellitus, and dysphasia, oropharyngeal phase. R26’s physician order and care plan required supervision with all meals, and the dining/eating assessment noted frequent cueing with meals, difficulty swallowing, and recent coughing or choking while eating. During breakfast observation, staff brought the tray to R26’s room and left, and the surveyor observed no staff supervision while R26 ate breakfast. CNA V stated they were unaware R26 required supervision until that day, while CNA W stated they only did frequent checks and were in the room for a few minutes. The DON stated that if a resident is supposed to have supervision with meals, staff should remain with the resident until they are done eating, and should not drop off the tray and leave.
Failure to Provide Ordered BiPAP Support
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for a resident who required BiPAP support. The resident was admitted with diagnoses including end stage renal disease, congestive heart failure, obstructive sleep apnea, and type 2 diabetes mellitus, and the most recent MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15. Hospital discharge orders dated 2/2/26 included BiPAP/NPPV use all night and when napping, with a full mask and specified settings of IPAP 16 and EPAP 12, but the facility did not transcribe the BiPAP order and the resident had not received BiPAP since admission. The facility also did not have a policy for respiratory care. The resident’s care plan identified the need for BiPAP due to OSA and stated the goal that the resident would tolerate use of BiPAP/CPAP/Trilogy Vent without complications, but the approaches were not added until 3/31/26. During survey observation, the resident stated the BiPAP machine was sitting on the floor because it had not been set up yet and said it was supposed to be worn every night and connected to oxygen. Staff interviews showed inconsistent understanding of the resident’s BiPAP use: one LPN said the resident had initially refused it and that refusals should be documented, while the DON, CSRN, and IP/WN gave differing statements about whether the resident wore BiPAP, refused it, or had an order. The CSRN stated they did not see an order, and after reviewing the hospital discharge orders, acknowledged the resident should have had a BiPAP order.
Dialysis Access Bleeding Emergency Plan Not Defined
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required dialysis. The facility did not ensure that a resident receiving dialysis had care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. The resident had end stage renal disease, congestive heart failure, obstructive sleep apnea, and type 2 diabetes mellitus, attended dialysis on Mondays, Wednesdays, and Fridays, and had a central venous catheter access site in the right upper chest. The resident’s care plan addressed the dialysis access site and included monitoring for complications such as localized infection, systemic infection, electrolyte imbalance, air embolus, dislodgement, infiltration, phlebitis, fluid overload, and dehydration, but it did not include an emergency plan for bleeding from the dialysis access site. The physician orders also did not include monitoring of the dialysis site or instructions for staff regarding an emergency plan. During interviews, a CNA stated they would get the nurse and assist, an LPN stated they would call the provider and try to stop the bleeding, and the DON stated staff should apply pressure, call for help, dial 911, and send the resident to the hospital. The facility’s policies titled Pre-Dialysis Patient Assessment and Post-Dialysis Assessment did not include an emergency plan.
Expired oxycodone remained in medication cart and was administered after expiration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when it did not ensure accurate acquiring, receiving, dispensing, and administering of medications and biologicals for one resident. During medication storage review of 2 of 3 medication carts, surveyors found that R33’s oxycodone remained in circulation after the printed expiration date on the medication card. The facility policy stated that expiration dates for all medication in inventory are to be recorded and monitored monthly so medication is replaced before expiration. R33 was admitted with diagnoses including encephalopathy, pain in the left hip, and generalized anxiety disorder, and had an order for oxycodone 2.5 mg by mouth every 12 hours as needed. On observation, R33’s oxycodone 5 mg tablets were found with an expiration date of 3/16/26, with three tablets remaining in the package. RN L confirmed the medication had expired and should not have been in circulation, and the MAR showed the oxycodone had been administered on 3/19/26 and 3/20/26 after the expiration date. DON B and CSRN O stated pharmacy staff had recently been in the facility to review medication cards, but the expired medications were missed, and they expected both expired medications to have been disposed of.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility did not ensure that drugs and biologicals were stored in accordance with currently accepted professional principles when expired medications were found in a medication cart for two residents. During observation on 3/30/26 at 4:00 PM, the surveyor observed R5’s lorazepam 0.5 mg tablets in the medication cart for rooms 18-46 with an expiration date of 1/17/26, and 14 tablets remained in the package. RN L confirmed that the lorazepam had expired and should not have been in circulation, and asked LPN M to dispose of it. At the same time, the surveyor observed R33’s oxycodone 5 mg tablets in the same medication cart with an expiration date of 3/16/26, and three tablets remained in the package. RN L confirmed that the oxycodone had expired and should not have been in circulation, and asked LPN M to dispose of it. On 3/31/26, the DON and CSRN stated that pharmacy audits medications and disposes of expired medications, nursing staff also perform random checks, and pharmacy had been in the facility the week before to review medication cards but had missed the two expired medications found in the cart.
Infection Control Breaches During Wound Care and Contact Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 1 resident observed for wound care and 1 resident on transmission-based precautions. During wound care for a resident with a wound, the Infection Preventionist/Wound Nurse cleansed, rinsed, and dried the wound, applied skin prep to the periwound, and inserted collagen into the wound bed without changing gloves or performing hand hygiene after the wound cleansing and before moving from dirty to clean tasks. The same staff member then removed gloves, put on a new pair, and applied a bordered dressing without hand hygiene between glove changes. When interviewed, the staff member stated hand hygiene and glove changes were needed when going from dirty to clean, and the DON stated gloves are considered contaminated after cleansing a wound and hand hygiene is needed after glove removal before applying new gloves. A resident admitted with diagnoses including sepsis due to E. coli, ESBL resistance, and acute pyelonephritis was on contact precautions with a sign posted on the door. While wearing gown and gloves in the doorway, an LPN handed the resident’s drinking cup to a CNA to take down the hallway and refill, and the cup was later brought back and placed on the medication cart in the hallway. The cup still contained a small amount of soda when it was removed from the room. The LPN stated the cup should not have been taken out of the room and soda should have been brought to the resident instead, and the CSRN stated drinking cups should not be removed, refilled, and brought back into the room for a resident on contact precautions.
Failure to Develop Comprehensive, Person-Centered Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan that addressed the medical, physical, mental, and psychosocial needs of a resident with multiple diagnoses, including dementia, chronic pain, anxiety, and type 2 diabetes. The resident required significant assistance with activities of daily living (ADLs), such as eating, hygiene, dressing, transfers, and was frequently incontinent of urine and bowel. Despite these needs, the resident's comprehensive care plan and resident profile lacked specific approaches or interventions for staff to follow, leaving essential care areas such as incontinence, ADLs, blood glucose management, pain, and anxiety unaddressed in the care plan documentation. Interviews with CNAs revealed that staff relied on the resident profile for care instructions, but were unable to find any approaches for the resident in question. Both the Nursing Home Administrator and Director of Nursing acknowledged the absence of care plan approaches and confirmed that they should have been present. The facility's own policy required that care plans be comprehensive, person-centered, and regularly updated to reflect the resident's needs, but these requirements were not met for this resident.
Inadequate Staff Assistance During Resident Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, R6 and R5, by not adhering to the required staff assistance during transfers. R6, who has chronic diastolic heart failure, anxiety disorder, and bilateral artificial knee joints, was care planned for pivot transfers with the assistance of two staff members using a gait belt or walker. However, R6 reported that sometimes only one staff member assisted with transfers, and CNA C admitted to performing solo transfers for R6, despite the care plan's requirements. Similarly, R5, who has atherosclerotic heart disease and vascular dementia, was care planned to require a Hoyer lift and assistance from two staff members for all transfers. Despite this, CNA C acknowledged transferring R5 alone when other staff were unavailable. The Director of Nursing confirmed that both R6 and R5 should have been transferred with the assistance of two staff members, as per their care plans. This failure to follow the care plans and ensure adequate staff assistance during transfers led to the deficiency identified by the surveyors.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours on January 1, 2025, as required by regulations. This deficiency was identified during a review of nursing staff schedules and postings from December 23, 2024, to January 6, 2025, which revealed that no RN was scheduled or present for any of the three shifts on that day. The Director of Nursing (DON) confirmed during an interview that an RN was expected to be in the building every day for at least 8 consecutive hours and acknowledged that the scheduled RN had called in, resulting in the absence of RN coverage. This oversight had the potential to affect all 33 residents residing within the facility.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 33 residents. Surveyors observed multiple instances of non-compliance with food safety standards. Staff members, including the Director and Assistant Director of Food Services, were seen preparing meals without proper hair restraints, despite the facility's policy requiring hair over 1/8 of an inch to be covered. Additionally, the facility did not maintain records of manual temperature monitoring for the dishwasher, as required by their policy, which could compromise the sanitation of dishware. Further observations revealed that the facility had expired food items, such as cottage cheese and V8 juice, still in circulation, and dented cans of tuna and creamed corn were not discarded as per policy. There was also an instance of a food item being removed from its original packaging without proper labeling or dating. These deficiencies indicate a lack of adherence to professional standards for food safety and sanitation, as outlined by the FDA Food Code 2022 and the facility's own policies.
Inadequate Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, which was evident during a COVID-19 outbreak. The facility did not conduct contact tracing or complete appropriate testing of residents and staff. The staff line list was incomplete, missing information such as the last day worked and the area worked in, which hindered the facility's ability to track and trend staff illnesses. Additionally, the facility's outbreak policy was not clearly understood by the staff, as evidenced by the lack of documentation for contact tracing and testing during the outbreak. Multiple instances of staff not adhering to proper infection control practices were observed. Staff members were seen not wearing appropriate personal protective equipment (PPE) when administering eye drops to a resident and when providing care to a resident under enhanced barrier precautions. Furthermore, a CNA was observed using a personal cell phone and then assisting a resident with a meal without performing hand hygiene in between, which is a breach of infection control protocols. The facility also failed to manage a resident's urinary catheter properly, as it was observed in direct contact with the wheel of the resident's wheelchair while in motion. This resident had a history of recurrent urinary tract infections, and the catheter's improper handling could contribute to further infections. These observations highlight significant lapses in the facility's infection prevention and control measures, potentially affecting the entire resident census.
Resident Dignity Compromised During ADLs
Penalty
Summary
The facility failed to ensure that a resident, identified as R13, was treated with dignity and respect during the provision of activities of daily living (ADLs). R13, who has moderate cognitive impairment and was admitted with diagnoses including anorexia, weakness, and adult failure to thrive, expressed a preference not to be taken to the dining room in her pajamas. Despite this, the staff transferred R13 to breakfast in her pajamas, which made her feel like a low-class citizen and compromised her sense of vanity. The incident occurred because the certified nursing assistants (CNAs) were running behind schedule and prioritized other tasks, such as assisting residents who were going home that day, over R13's expressed preferences. The CNAs decided not to dress R13 before breakfast to avoid undressing her again for a shower scheduled after breakfast. This decision was made without consulting R13, who felt terrible and embarrassed when another resident commented on her attire. The facility's failure to respect R13's preferences and dignity was acknowledged by the staff, including a Clinical Registered Nurse (CRN) and the Director of Nursing (DON), who agreed that the situation could be considered a dignity issue and a violation of resident rights. The facility's documentation on resident rights emphasizes the importance of treating residents with respect and dignity, which was not upheld in this instance.
Failure to Maintain Clean and Comfortable Environment for Resident
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable environment for a resident, identified as R18, who was on hospice care and had diagnoses including metabolic encephalopathy and depression. R18, who was cognitively intact, expressed concerns about the cleanliness of her room, noting that it was not cleaned often. The surveyor observed dust accumulation on various surfaces in R18's room and debris on the carpeting. R18 reported that her room had not been cleaned for a couple of weeks and that housekeeping did not clean her room daily. The Environmental Services staff member, ES Q, confirmed the lack of regular cleaning, citing insufficient housekeeping staff and indicating that R18's room was cleaned last. There was no sign-off sheet to track when rooms were cleaned, and the Nursing Home Administrator (NHA A) acknowledged the expectation for daily cleaning but admitted there was no current system to verify this. The deficiency was identified through observations, interviews, and record reviews, highlighting a failure to maintain a sanitary and orderly environment for R18.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services consistent with professional standards of practice. The resident, who has a Stage III pressure ulcer on the sacrum, spent approximately five hours sitting in a wheelchair without a pressure-relieving cushion during an appointment. This was contrary to the facility's guidelines, which require pressure-reducing cushions for residents at risk of pressure ulcers. Interviews with staff confirmed that the resident should have had a cushion in the wheelchair, but it was not provided. Additionally, an air mattress was placed on the resident's bed without staff knowledge of the manufacturer's recommendations for proper inflation. The air mattress was obtained from storage, and staff, including the maintenance team, were unaware of the brand or the correct amount of air required for effective use. The Director of Nursing acknowledged that the mattress would not be effective if not properly inflated, which could potentially cause harm. The lack of instructions and staff education on the use of the air mattress contributed to the deficiency.
Failure to Prevent Falls and Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident identified as R16, who was at moderate risk for falls. R16 experienced multiple falls within the facility, and the staff did not document the details of these falls, nor did they update the resident's medical doctor or power of attorney. Additionally, the facility did not initiate neuro checks according to its policy, and a Registered Nurse Assessment post-fall was not recorded. The facility also failed to identify the root causes of R16's falls and did not implement individualized interventions to prevent further incidents. R16's care plan was not adequately updated to reflect the resident's needs and preferences, such as sleeping in a recliner and having the lights and TV on, which were known to the staff but not acted upon. Despite the resident's family reporting these preferences, the facility did not incorporate them into the care plan or attempt alternative interventions while waiting for a scoop mattress to arrive. This delay in obtaining the scoop mattress, coupled with the lack of increased supervision or alternative measures, resulted in R16 experiencing additional falls. The facility's policy on fall management was not followed, as evidenced by incomplete documentation of fall events and a lack of thorough investigation into the causes of the falls. The facility did not engage in a comprehensive review by the interdisciplinary team to evaluate the appropriateness of interventions. The staff's failure to recognize and address the resident's specific needs and preferences contributed to the repeated falls and the facility's inability to prevent further accidents.
Inadequate Pain Management for Resident with Fracture
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as R182, who was admitted with a right humerus fracture and other medical conditions such as type 2 diabetes and neuropathy. Upon admission, R182 had orders for various pain medications, including oxycodone, acetaminophen, lidocaine patches, and Voltaren gel. However, the facility did not obtain the ordered narcotics, and R182 began refusing acetaminophen due to difficulty swallowing, leading to continued pain. The facility's policy on pain management was not followed, as there was a lack of documentation regarding pain assessments and interventions. R182 experienced significant pain, with documented pain ratings reaching as high as 7 out of 10. Despite this, the facility did not ensure timely access to prescribed medications, such as oxycodone, and failed to address the resident's refusal of acetaminophen due to its uncoated form causing discomfort. The care plan for R182 was incomplete and did not specify the resident's pain tolerance level or preferred non-pharmacological interventions. Additionally, there was a delay in obtaining a new order for coated acetaminophen tablets, which the resident preferred. Interviews with facility staff revealed that there was a lack of communication and follow-up regarding the missing oxycodone prescription and the resident's refusal of acetaminophen. The nursing staff did not notify the physician or the on-call provider about the need for a new prescription or the resident's medication preferences. The Director of Nursing acknowledged that the staff should have confirmed the receipt of the oxycodone script with the pharmacy and taken steps to address the resident's medication refusal. This deficiency in pain management resulted in R182 experiencing ongoing pain and distress.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate during a medication pass task. Three errors were identified among 25 opportunities, affecting three residents. The errors included late administration of medications and improper timing related to meal administration. Specifically, one resident received Tylenol significantly later than the prescribed time, another resident received Vitamin B-12 and Vitamin D3 late, and a third resident received short-acting insulin without receiving a meal within the required timeframe. The first resident, who has severe cognitive impairment and multiple diagnoses including dementia and polyosteoarthritis, was supposed to receive acetaminophen at 7:00 AM but was administered the medication at 8:42 AM. The Director of Nursing confirmed that this was a medication error as it was not documented that the resident refused the medication at the scheduled time. The second resident, who is cognitively intact and has cerebrovascular disease and chronic systolic heart failure, received their vitamins at 8:51 AM instead of the scheduled 7:00 AM, which was also confirmed as a medication error by the Director of Nursing. The third resident, with moderate cognitive impairment and diagnoses of Type 2 Diabetes Mellitus and Major Depressive Disorder, received insulin aspart 49 minutes before receiving a meal, contrary to the best nursing practice of administering short-acting insulin 15 minutes before meals. The Clinical Registered Nurse confirmed that the resident should have received their meal within 15 minutes of the insulin administration. These errors highlight a failure to adhere to the facility's medication administration policy and best nursing practices.
Failure to Offer Influenza Vaccine to Resident
Penalty
Summary
The facility failed to offer influenza immunizations to a resident, identified as R16, during the current flu season, as required by their policy. R16 was admitted to the facility and initially refused the influenza vaccine upon admission, as documented in the Admission Immunization Consent Packet. However, there was no evidence in R16's medical record that the influenza vaccine was offered again during the current flu season, nor was there documentation of any education provided regarding the risks and benefits of the vaccine. During an interview, the Clinical Registered Nurse (CRN I) and the Director of Nursing (DON B) confirmed that the facility's process involves offering the vaccine at least three times and providing education if initially declined. This process should be documented in the progress notes. Despite this protocol, R16's medical record lacked documentation of any subsequent offers or education about the influenza vaccine after the initial refusal, indicating a failure to adhere to the facility's immunization policy.
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 261 citations issued within 25 miles in the last 12 months — including the 6 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 Sun Prairie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avina Of Sun Prairie | 1.2 mi | ★★★★★ | 10 | 0 |
| Oakwood Village East Health And Rehab Center | 3.9 mi | ★★★★★ | 2 | 1 |
| Oak Park Nursing And Rehab Center | 7.4 mi | ★★★★★ | 41 | 3 |
| Madison Health And Rehabilitation Center | 7.8 mi | — | 39 | 0 |
| Capitol Lakes Health Center | 11.6 mi | ★★★★★ | 11 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.