Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunrise Health Services during CMS and state inspections, most recent first.
A resident with stroke, diabetes, COPD, CHF, pulmonary hypertension, right-sided weakness, aphasia, and dependence on staff for toileting was the subject of a neglect allegation after a family member reported the resident was not being changed, was spoken to rudely by a CNA, and was not given water. The facility’s investigation documentation did not show that other residents were interviewed about their care by CNAs, despite policy requiring interviews of all involved persons and others who might have knowledge of the allegation. The DON later produced resident interviews, but follow-up revealed these were conducted weeks later rather than at the time of the incident, and the Administrator acknowledged that resident interviews were not obtained during the original investigation.
A facility failed to follow the posted lunch menu for residents on altered-texture diets. During meal service, a Dietary Aide served the regular-texture residents a garlic dinner roll with butter, but seven residents on altered-texture diets were given no dinner roll or substitution, even though the menu included one and the facility had textured consistency options available. The DM later stated the altered-texture dinner rolls were forgotten and that all residents get the same menu items.
Unlabeled and undated food items were found in the 1st and 2nd floor kitchenette refrigerators and freezers, including opened containers, loose produce, and beverages with no labels or open dates. During lunch temperature checks, a DA used the same paper towel to wipe the food thermometer between multiple foods and did not sanitize it between items, despite the DM stating the thermometer should be sanitized between foods.
Surveyors observed that insulin pens and vials on a medication cart were not properly labeled with resident names or dates opened, and some were expired. An LPN was unable to clarify labeling discrepancies or expiration periods, and the facility's policy for labeling and discarding insulin after 28 days was not followed. These findings were shared with the administrator and DON, but no additional information was provided.
A resident’s DNR advance directive was not implemented because the EHR and physician order still listed Full Code even though the guardian signed a CPR/DNR form indicating no CPR. Staff reported they would rely on the computer dashboard for code status, and the resident was observed without a DNR bracelet. The code status was not updated to DNR until the concern was brought to the DON’s attention.
A resident with severe cognitive impairment, dysphagia, dementia, and a G-tube had a care plan and restraint-related order for an abdominal binder, but staff interviews and observations showed the binder was not being worn and some staff said the resident never pulled at the tubing. Despite MAR/TAR documentation showing 2-hour binder checks and releases, the care plan was not revised to clearly match the resident’s actual needs or current use of the binder.
A resident with a Foley catheter, severe cognitive impairment, and total ADL dependence had the catheter bag and tubing observed lying on or touching the floor during multiple observations, with no barrier between the drainage system and the floor. The care plan included catheter care, and an LPNUM stated staff should ensure the bag does not touch the floor; the DON acknowledged this should not have happened.
A resident with severe cognitive impairment and hospice services had hospice notes that were not readily available for staff communication and care coordination. The hospice binder was initially missing, later found with another resident’s records inside, and the binder lacked nursing visit notes even though only a CNA entry was documented. Staff relied on in-person contact or a phone number in the binder to communicate with hospice, but the nursing notes were not updated in the medical record or binder until the surveyor requested them.
The facility did not ensure that residents had ongoing access to their personal funds, as withdrawals could only be made during limited weekday hours when designated staff were present. No petty cash was available for evenings, weekends, or holidays, and there was no posted information about fund access, affecting multiple residents whose funds were managed by the facility.
A resident with multiple comorbidities and high risk for pressure injuries was admitted without any skin breakdown, but the facility failed to develop and implement a comprehensive skin integrity care plan. Staff did not consistently perform required foot inspections, repositioning, or offloading of heels, and treatments for multiple pressure injuries were delayed. Observations and interviews revealed that care plan interventions such as Prevalon boots were not routinely used, and documentation of care was incomplete, resulting in the development and delayed treatment of several pressure injuries.
Seven staff members, including a dietary aide, an LPN, five CNAs, and a contracted speech language pathologist, did not receive required behavioral health training as outlined in the facility's assessment. The facility lacked documentation and a formal policy for such training, despite having a significant percentage of residents with psychiatric diagnoses. The only training provided was an inservice on abuse, which did not address the specific behavioral health needs of the resident population.
A resident requiring CPR was attended to by staff, including an LPN whose CPR certification had expired, contrary to facility policy requiring current certification and availability of CPR-certified staff at all times. The facility was unable to promptly verify staff certification status, and emergency responders noted low-quality CPR was being performed.
A resident with a left patella fracture and Parkinson's disease experienced frequent displacement of a knee immobilizer, which staff routinely readjusted but did not report or escalate to the physician. Despite facility policy requiring monitoring and documentation of assistive device issues, staff did not assess or address the risk, leading to failure of the surgical repair as confirmed by the orthopedic surgeon.
A resident with severe cognitive impairment and a history of falls was left alone on the toilet by a CNA, despite care plan instructions requiring assistance. The resident attempted to self-transfer and experienced an unwitnessed fall. Facility documentation inconsistently identified the resident's fall risk, and a required post-fall assessment was not completed.
A resident with chronic kidney disease and other conditions did not receive an updated sodium bicarbonate dosage as ordered by a nephrologist, due to the facility's failure to process the new order. Additionally, staff left medications for a family friend to administer, contrary to facility policy, and there was no documentation or care plan supporting this practice.
A resident fell from bed and was found unresponsive due to the facility's failure to ensure the bed was in a low position and provide adequate supervision. The resident's care plan required a low bed due to fall risk, but the bed was elevated for television viewing without necessary safety adjustments. The resident suffered positional asphyxia and other injuries, resulting in death.
A facility failed to provide appropriate treatment and services for a resident with dementia, leading to escalated behavioral symptoms and an incident where the resident ran over another resident's foot with a wheelchair. Despite significant behavioral changes, the facility did not conduct a comprehensive assessment or timely revise the care plan, resulting in immediate jeopardy.
The facility failed to notify a resident's POA when a CBC and UA were ordered. The resident, with severe impairment and multiple diagnoses, had a POA activated, but the facility did not inform the POA as required by their policy. The lapse was confirmed through interviews and record reviews.
A resident with Alzheimer's and severe impairment sustained a left forearm fracture and had a purple, painful right middle toe. The facility failed to consistently monitor these injuries or update the care plan, despite multiple staff notes and the resident's complaints of pain. The resident was eventually discharged to the hospital with noted bruising and swelling.
A resident was not provided timely therapy services as required by physician orders and facility policy. Despite multiple diagnoses and a decline in condition, the necessary evaluations for speech, physical, and occupational therapy were not conducted, leading to a deficiency.
The facility failed to inspect and maintain bed frames and rails according to the Manufacturer's Instructions for Use, affecting four residents and potentially all 94 residents using beds. The Maintenance Director did not document inspections for occupied beds, contrary to facility policy and manufacturer guidelines.
The facility failed to properly label and store medications, with surveyors finding expired and unlabeled medications in two medication carts and one medication room. Medications such as eye drops and liquid medications lacked open dates, and expired medications were not removed from stock. Additionally, cleanliness issues were noted in the second-floor medication cart.
A resident who went out on therapeutic leave was not allowed to return to the facility due to lack of communication and absence of a bed hold policy. Despite multiple attempts to arrange her return, the facility considered her absence as a self-discharge and did not provide proper notice or consider her unstable housing situation.
The facility failed to attempt alternatives to bed rails and did not obtain informed consent for their use in two residents with moderate cognitive impairment. The facility's policy requires documentation of attempted alternatives and informed consent, which was not followed, putting residents at risk.
The facility failed to provide written transfer or discharge notices to six residents and their representatives, as required by policy and regulation. These notices should have included the reason for transfer, the place of transfer, and information on how to appeal the transfer. The deficiency was identified during a review of records, interviews, and policy examination, revealing that the facility did not adhere to its own policy of notifying residents and their representatives in writing, especially in cases of emergent hospital transfers.
Failure to Conduct Timely and Thorough Neglect Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving one resident. The resident had been readmitted with diagnoses including stroke and diabetes, and had an ADL care plan indicating an ADL self-care deficit related to COPD, CHF, pulmonary hypertension, right-sided weakness, and aphasia, with an intervention requiring assist of two for toileting. A significant change MDS with an ARD of 01/16/26 showed the resident had a BIMS score of 10/15, indicating moderately impaired cognition, and was dependent on staff for toileting. A facility investigation dated 01/14/26 documented that a family member reported the resident had not been changed, was calling more often to express concerns, that a CNA spoke to the resident in a rude manner, and that water was not given to the resident. Review of the investigation file showed no evidence that other residents had been interviewed to determine if they had concerns about care provided by CNAs, despite the facility’s abuse, neglect, and exploitation policy requiring identification and interviews of all involved persons, including others who might have knowledge of the allegations. When the DON was asked about resident interviews, the DON later produced interviews but stated they were thought to be in another folder. Follow-up on 02/23/26 revealed that the identified residents had actually been interviewed on that date, not at the time of the original investigation. On 02/25/26, the Administrator acknowledged that resident interviews were not obtained at the time of the investigation, demonstrating that the facility did not conduct an immediate and complete investigation as required by its policy.
Altered-texture residents did not receive menu dinner rolls
Penalty
Summary
The facility did not ensure menu items were followed for residents receiving altered textured diets. On 7/21/2025 at 12:06 PM, a surveyor observed the lunch meal being served on the 1st floor by Dietary Aide M. The posted lunch menu included Turkey Alfredo, parslied fettuccini, Tuscany blend vegetables, a garlic dinner roll, and strawberry shortcake for dessert. The surveyor observed that there was not a puree or mechanically altered dinner roll option available, and residents R31, R16, R54, R88, R50, R26, and R10, all of whom had altered textured diets, were served on divided plates without a garlic dinner roll or any substitution. Residents on regular textured diets were provided a dinner roll with butter. On 7/22/2025, the Dietary Manager stated the usual staff was not serving the noon meal the prior day and that textured consistency options for dinner rolls do exist, but they were forgotten. The Dietary Manager also stated that all residents get all the same menu items. The facility policy titled Menus, dated 9/2017, states menus will be served as written unless a substitution is provided in response to preference, unavailability of an item, or a special meal. The concern was shared with the DON and SVPOS, and the Regional Director stated education for kitchen staff had started.
Unlabeled Food Items and Unsanitized Thermometer Use
Penalty
Summary
Food and beverages were not maintained in a sanitary manner in 2 of 2 kitchenette serving areas. On 7/21/2025, the 1st floor kitchenette refrigerator and freezer contained multiple unlabeled or undated items, including opened popsicles, an unlabeled Styrofoam container, a deli container with a brownish-green substance, two plastic bagged containers, an open jar of queso, a Styrofoam drink with a straw, sliced raw onion in loose saran wrap, and a brown bag with purple grapes. The 2nd floor kitchenette also contained unlabeled or undated items, including an opened fast-food container, a frozen red Styrofoam drinking cup with lid, a used dessert icing bag, a frozen Italian Ice pop box, a yellow tied grocery bag with frozen items, an opened honey container, a quart of opened chocolate milk with no open date, a loose apple, and a gray tied bag with two small oranges. During lunch meal temperature checks on the 1st floor kitchenette, the Dietary Aide used the same paper towel to wipe the food thermometer between multiple foods and did not sanitize the thermometer between items. The thermometer was used on turkey alfredo, mechanical soft turkey alfredo, puree noodles, puree carrots, mechanical soft carrots, a carrot and cauliflower mix, and puree strawberry shortcake without sanitizing between foods. The Dietary Manager stated the kitchenette refrigerators are checked daily and that the process is to sanitize the thermometer between foods when taking temperatures.
Insulin Labeling and Expiration Deficiencies on Medication Cart
Penalty
Summary
Surveyors found that the facility failed to ensure drugs and biologicals were labeled and stored according to professional standards and facility policy. During observation of a medication cart, an aspart insulin pen was found with two different dates written on it, and the LPN present was unable to clarify which date was correct. Additionally, a Humalog insulin pen was discovered without a resident name label, and a Lispro insulin vial was found with a date indicating it was expired. The LPN was unsure about the correct expiration period for insulin and acknowledged that the insulins observed were expired. The facility's policy requires that multi-dose vials be labeled with the date opened and the initials of the first user, and that insulins such as Humalog and Aspart be discarded 28 days after opening. The surveyor discussed these findings with the Nursing Home Administrator and the Director of Nursing, but no further information was provided to address the labeling and expiration concerns identified during the inspection.
Advance Directive Not Reflected in Code Status
Penalty
Summary
The facility did not ensure that a resident’s advance directive for do not resuscitate (DNR) was implemented. R8’s electronic health record showed the resident as Full Code, and the physician order also documented Full Code, even though a CPR/DNR preference form signed by R8’s guardian/legal decision maker indicated that CPR should not be attempted. R8’s care plan documented that the resident had an advance directive in place and that staff should follow the advance directive and facility protocol for code status identification. During record review and staff interviews, surveyors found that nursing staff relied on the computer dashboard as the source for code status and identified R8 as Full Code. RN-F stated he would look at the dashboard for code status and confirmed that R8 was listed as Full Code there. LPN-G also stated he would look at the computer main screen for code status and would trust the computer over a DNR bracelet if there was a discrepancy. R8 was observed wearing an allergy bracelet but not a DNR bracelet. The EHR code status was later changed to DNR after the concern was brought to the DON’s attention, but as of one week later the resident’s code status had remained Full Code until surveyor notification.
Care Plan Not Revised for Abdominal Binder and G-Tube Monitoring
Penalty
Summary
The facility did not ensure that 1 of 18 residents reviewed had a care plan revised after assessment or as determined by the resident’s needs. The resident had diagnoses including hemiplegia/hemiparesis following cerebral infarction with right-sided paralysis, dysphagia, aphasia, type 2 diabetes mellitus, protein-calorie malnutrition, Alzheimer’s disease, and dementia. The resident’s admission MDS indicated severely impaired cognition with a BIMS score of 0 and total assistance needed for all ADLs. The resident was admitted with a G-tube for continuous feedings, a foley catheter, and an activated POA. The resident’s care plan included a need for a feeding tube/potential for complications of feeding tube use related to swallowing impairment and documented that the resident pulled at the G-tube at times, with an intervention for an abdominal binder to keep the G-tube from being pulled out. A physical restraint assessment documented that the abdominal binder was to be worn at all times to prevent dislodgement of the G-tube, with monitoring and opening of the binder every 2 hours. A physician order also directed that the abdominal binder be released for 15 minutes every 2 hours, with skin and circulation checks and notification of the MD/NP if changes were noted. During survey interviews and observations, multiple staff stated the resident was not wearing an abdominal binder and that they had not seen one in the resident’s room. One LPN stated the resident did not wear an abdominal binder and had never pulled at the tubing, while another LPN stated the resident had worn one in the beginning but no longer did because the resident never pulled or tried to remove the tubing. The DON and LPN unit manager stated the resident never came to the facility with an order to wear an abdominal binder and that the order had been obtained to address the POA’s concern. Survey review of the MAR/TAR showed staff initialing the binder being taken off every 2 hours per order, even though staff could not confirm the resident was actually wearing it, and the care plan was not revised to clearly reflect the resident’s current need or lack of need for the abdominal binder.
Improper Foley Catheter Positioning and Care
Penalty
Summary
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections was not ensured for 1 resident reviewed with an indwelling catheter. The resident was admitted with a Foley catheter and had diagnoses including hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side, dysphagia, aphasia, type 2 diabetes mellitus, spinal stenosis, presence of urogenital implants, Alzheimer's disease, and dementia. The resident's MDS indicated severely impaired cognition with a BIMS score of 0, and the facility assessed the resident as requiring total assistance with one staff member for all ADL care. The care plan included indwelling urinary catheter use due to disease process and recent stroke with deficits, with catheter care as an intervention. During observations on 7/22/2025 and 7/23/2025, the resident's catheter collection bag and tubing were seen lying directly on the floor or touching the floor, and no barrier was observed between the catheter drainage system and the floor. On 7/23/2025, the surveyor interviewed the DON and LPNUM about catheter care, and the LPNUM stated staff are to provide catheter care, empty the catheter, ensure the bag has a privacy cover, and make sure the catheter bag does not touch the floor. The DON stated that the catheter bag being on the floor should not have happened.
Hospice Notes Not Readily Available for Care Coordination
Penalty
Summary
The facility did not ensure that a resident’s hospice notes were readily available for communication and collaboration of care in accordance with professional standards of practice for one resident receiving hospice services. The resident had diagnoses including type 2 diabetes mellitus, dementia, and hypertensive chronic kidney disease, and the Quarterly MDS documented a BIMS score of 00, indicating severe cognitive impairment, with the resident rarely or never making self-understood or understanding others, always incontinent of bowel and bladder, and having range of motion impairment in both upper and lower extremities. The resident also had a hospice care plan in place with interventions related to end-of-life care, ADL assistance, pain management, honoring advanced directives, and hospice staff visits. During survey observations and interviews, the hospice binder for the resident was initially not located with the other residents’ binders, and staff stated it may have been taken by hospice with another resident’s binder. When the binder was later found, the last documented entry was a CNA visit, and nursing visit notes were not present in the binder at that time. Staff interviews indicated communication with hospice occurred by phone number in the binder or in person when hospice staff were present, but the resident’s hospice communication binder was not available for staff review for continued communication and coordination of care until the surveyor requested it. The surveyor also noted that nurse visit notes were not updated in the resident’s medical record or hospice binder until requested.
Failure to Provide Residents Ongoing Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents had consistent access to their personal funds held by the facility, as required by federal and state regulations. According to interviews and record review, the Business Office Manager (BOM) was primarily responsible for managing resident funds and was typically available only during weekday business hours. The Social Services Coordinator (SSC) also had access to the safe but worked limited weekday hours. Neither the BOM nor the SSC were present during evenings, weekends, or holidays, and there was no petty cash fund available for residents to withdraw money during these times. The facility did not have posted banking hours or information regarding the availability of funds for withdrawal. Staff interviews confirmed that if residents wanted to access their funds outside of the BOM or SSC's working hours, they would need to plan ahead, as there was no system in place to accommodate requests during evenings, weekends, or holidays. The Administrator acknowledged that there had never been an instance where a resident requested funds during these times, but also recognized the lack of a process for such situations. At the time of the survey exit, the facility had not provided additional information to explain why residents did not have ongoing access to their funds, affecting 42 residents whose personal funds were managed by the facility.
Failure to Prevent and Treat Pressure Injuries in High-Risk Resident
Penalty
Summary
A resident was admitted to the facility without any pressure injuries but was identified as being at high risk for pressure injury development due to multiple comorbidities, including diabetes mellitus, chronic kidney disease, and peripheral vascular disease. Despite this high risk, the facility failed to develop a comprehensive skin integrity care plan upon admission, and the care plans in place did not address necessary interventions such as repositioning or offloading of the resident's feet and heels. The facility's own policy required a baseline plan of care and interventions based on risk factors, but these were not implemented in a timely manner. Additionally, staff did not consistently inspect the resident's feet as required, and documentation of these assessments was lacking in the medical and treatment administration records. The resident subsequently developed multiple pressure injuries, including unstageable pressure injuries and suspected deep tissue injuries on the right ankle, heel, inner ankle, top of the right foot, and right toe. These injuries were not identified and treated promptly; treatments were not ordered until two days after the injuries were first documented. Furthermore, the treatment administration records did not show that ordered treatments were completed on the initial days following the orders. Observations during the survey revealed that the resident was frequently not wearing Prevalon boots as required by the care plan, and her heels were often not offloaded, with staff failing to implement these interventions during routine care and repositioning. Interviews with staff indicated a lack of awareness regarding the resident's care plan requirements, and some staff reported difficulty providing care due to the resident's pain and cognitive impairment. Family members also reported that staff were not consistently providing incontinence care or repositioning the resident as required. The facility's failure to provide necessary care and services to prevent the development and promote the healing of pressure injuries, as well as the failure to develop and update appropriate care plans, led to the finding of Immediate Jeopardy.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to ensure that seven randomly selected staff members, including a dietary aide, an LPN, five CNAs, and a contracted speech language pathologist, received behavioral health training as required by the facility's own assessment and regulatory standards. The facility was unable to provide documentation of behavioral health training for these staff members, nor did it have a policy or procedure outlining training requirements for all employees and contracted personnel. The facility assessment, last reviewed on 8/5/24, indicated that staff should be educated on caring for residents with mental and psychosocial disorders, trauma, and psychiatric diagnoses, but behavioral health was not listed as a training topic in the assessment. The assessment also documented that approximately 57% of residents had a psychiatric diagnosis, including anxiety, bipolar disorder, mood disorder, schizoaffective disorder, schizophrenia, depression, and developmental disorder. During interviews, the nursing home administrator confirmed that there was no formal behavioral health training in place to address the needs of residents with psychiatric diagnoses or behavioral health issues. The administrator also stated that monitoring of required trainings had been the responsibility of human resources, but this role had recently shifted to the administrator. The only documentation provided related to an inservice on abuse, which did not include specific training on the psychiatric diagnoses present in the facility or interventions tailored to those conditions.
Failure to Ensure CPR-Certified Staff Available and Aware of Certification Status
Penalty
Summary
The facility failed to ensure that staff responsible for providing CPR were properly certified and that the status of staff CPR certifications was accurately tracked and known. During an incident where a resident was found unresponsive and without a pulse, staff initiated CPR as per the resident's documented wishes and physician orders. However, one of the first responders, an LPN, was not currently certified in CPR at the time of the event, as their certification had expired the previous year. The facility's policy required that CPR-certified staff be available at all times and that staff maintain current certification, but the facility was unable to provide documentation confirming the certification status of all staff involved, and the Human Resources department responsible for tracking certifications was in disarray due to recent staff turnover. Interviews with facility staff revealed a lack of awareness regarding which staff members were CPR certified, and the Director of Nursing was still in the process of gathering certification records after the event. The quality of CPR performed was noted as low by emergency responders, and the resident ultimately passed away. The deficiency was further highlighted by the facility's inability to promptly produce a list of CPR-certified staff and the admission by the LPN involved that their certification had lapsed.
Failure to Address and Report Knee Immobilizer Issues Resulting in Poor Surgical Outcome
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received care and treatment in accordance with their care goals and physician orders, specifically regarding the use of a knee immobilizer following surgical repair of a left patella fracture. The resident, who had Parkinson's disease with associated tremors and spasms, required the immobilizer to be worn at all times except for skin checks. Despite this, the immobilizer frequently slipped out of place due to the resident's involuntary movements and activity level, which was observed and acknowledged by multiple staff members, including PT, CNA, RN, and DON. Staff routinely readjusted the immobilizer but did not document the issue or notify the resident's physician or orthopedic surgeon about the persistent problem. The facility's policy required staff to monitor the consistent and safe use of assistive devices, document problems, and modify the care plan as needed. However, staff did not assess the risk posed by the immobilizer's frequent displacement, nor did they implement or document interventions to address this risk. Interviews revealed that staff considered the slipping to be a normal consequence of the resident's condition and activity, and did not escalate the issue or seek alternative solutions, such as consulting with the physician about the appropriateness of the device or requesting a different immobilizer. As a result, the resident's surgical repair failed, with the orthopedic surgeon attributing the failure to the immobilizer not being in the correct position, which allowed the knee to flex and compromised healing. The lack of recognition, assessment, and intervention regarding the immobilizer's fit and function directly contributed to the poor outcome for the resident.
Resident Left Unattended During Toileting Resulting in Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with a history of falls, severe cognitive impairment, and significant physical limitations was left unattended while toileting, resulting in an unwitnessed fall. The resident required partial to maximal assistance for toileting and transfers, as documented in the care plan and assessments. Despite these documented needs, a CNA placed the resident on the toilet and instructed her to use the call light when finished, then left her alone. The resident subsequently attempted to self-transfer and fell, which was later discovered by staff responding to calls for help. The facility's documentation and assessments were inconsistent and did not accurately reflect the resident's fall risk status. The Admission Evaluation and subsequent Quarterly Clinical Reviews failed to identify the resident as being at risk for falls, despite a documented history of falls prior to admission and an unwitnessed fall occurring during the resident's stay. The care plan did include interventions such as not leaving the resident alone during toileting and providing assistance with transfers, but these were not followed at the time of the incident. Additionally, after the unwitnessed fall, the facility did not complete a post-fall assessment as required by its own policy. Staff interviews confirmed that the resident was left alone despite her need for assistance and severe cognitive impairment. The lack of accurate fall risk identification, failure to follow the care plan, and omission of a post-fall assessment contributed to the deficiency identified by surveyors.
Failure to Provide Pharmaceutical Services and Proper Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with multiple chronic conditions, including chronic kidney disease, diabetes mellitus, depressive disorder, anxiety disorder, and restless leg syndrome. A nephrology order was issued to increase the resident's sodium bicarbonate dosage to 1300 mg three times daily, but the facility did not process or implement this order. Instead, the facility continued administering the previous lower dose until a later change was made, and there was no documentation explaining why the new order was not transcribed or acted upon. The Unit Manager was unaware of the missed order and could not provide a reason for the failure to update the medication regimen as directed by the nephrologist. Additionally, the facility did not ensure that medications were administered according to policy, which requires that only authorized personnel administer medications and that the person who prepares the dose is the one who administers it. On observation, a medication cup containing pudding and crushed medication was left on the resident's over-bed table, and a family friend stated that the nurse left the medication for her to administer to the resident. Staff interviews confirmed that it was common for family or friends to be left with the responsibility of giving medications when the resident was resistant, despite the facility's policy prohibiting this practice. There was no evidence in the medical record of any education provided to the family or family friend regarding medication administration, nor was there a care plan addressing this practice. The Director of Nursing confirmed that medications should not be left for family or friends to administer, yet this had occurred on multiple occasions. The facility did not provide an explanation for why the medication order was not processed or why the medication was left for a non-staff member to administer.
Failure to Ensure Resident Safety and Adequate Supervision
Penalty
Summary
The facility did not ensure that a resident was as free of accident hazards as possible and did not provide adequate supervision and assistance devices to prevent accidents, resulting in a fall from bed. The resident was found unresponsive on the floor next to their bed, with no pulse. The medical examiner's preliminary autopsy report indicated that the resident suffered from possible positional asphyxia, a small epidural hemorrhage of the spinal cord, and hemorrhage of the posterior right neck soft tissue, which resulted in the resident's death. The resident's care plan required them to be in a low bed due to being a fall risk, but at the time of the incident, the bed was not in the low position, and the head of the bed was elevated. Staff were aware that the resident leaned to the right when in bed and had no trunk support, making it difficult for the resident to reposition themselves or stop from rolling. However, no interventions were put in place to create a barrier to prevent the resident from rolling out of bed. Additionally, the resident's television was positioned in a way that required the bed to be elevated for the resident to watch it, but no environmental adjustments were made to ensure the resident's safety while watching television. The facility's Fall Prevention and Management Guidelines policy required each resident to be assessed for fall risk and to receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls and reduce the possibility/severity of injury. The resident had multiple diagnoses, including hypertensive heart disease, type 2 diabetes mellitus, anemia, chronic atrial fibrillation, and vascular dementia. The resident's care plan included interventions such as keeping the bed in a low position, having commonly used articles within easy reach, and reinforcing the need to call for assistance. However, the facility failed to follow these interventions consistently. The resident's bed was not in the low position at the time of the incident, and the head of the bed was elevated, which contributed to the resident's fall and subsequent death. Interviews with staff members revealed that the resident was known to lean to the right when in bed and required assistance with mobility and personal care. The resident's bed was often elevated to allow them to watch television, but no adjustments were made to ensure the resident's safety while in this position. The facility's investigation into the incident did not provide specific details about the bed's position at the time of the fall, and there was no standard practice for what level from the ground was considered a low bed. The facility's failure to address the resident's positioning needs and ensure the bed was in the low position created a reasonable likelihood of serious harm, leading to a finding of immediate jeopardy.
Removal Plan
- Nursing staff will receive re-education on the Fall prevention and Management Guideline Policy. Education will include but is not limited to: Each resident's risk factors will be evaluated when developing an individualized plan of care, Interventions will be monitored for effectiveness, Monitoring changes in residents condition including balance and positioning
- Re-education was initiated and will continue prior to employees next shift to work.
- Staff will receive re-education on definition of low bed and bed in low position
- The ED, DON, and VPS reviewed the Fall Prevention and Management Guidelines policy and determined the policy identifies the compliance guidelines to provide services to minimize the likelihood of falls or reduce the possibility/severity of injury. No changes were required.
- Nursing management will re-evaluate residents with a care plan for bed in low position to determine if intervention is appropriate. Care plans will be updated based on the findings of the evaluations.
- DON and/or designee will complete audits on new admissions to ensure resident's at risk for falls have plans of care that are individualized and implemented by staff.
- DON and/or Designee will review 24 Hour Nursing Report/EMR Clinical Alerts to identify residents with a change of condition resulting in the need to re-evaluate fall risk and interventions.
- DON and/or Designee will audit Residents per week to determine if fall interventions are in place as per plan of care
- Results of the audits will be brought to QAPI for further review and recommendations.
- ADHOC QAPI held with IDT and Medical Director telephonically.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia, leading to an escalation of behavioral symptoms. The resident, who has a diagnosis of Alzheimer's disease and dementia, exhibited significant behavioral changes starting on 4/4/24, including verbal and physical aggression towards staff and other residents. Despite these changes, the facility did not conduct a comprehensive assessment to identify the cause of the behavior, nor did they revise the care plan in a timely manner. This lack of assessment and intervention resulted in the resident chasing another resident down the hall and running over their foot with a wheelchair. The facility's medication administration records for December 2023 through March 2024 did not document any behaviors, despite the resident's known history of behavioral symptoms. The care plan, which included interventions such as administering medications per physician orders and attempting psychotropic drug reduction, was not effectively implemented or monitored. The facility also failed to conduct dementia or trauma assessments, which are crucial for understanding and managing the resident's behavior. Interviews with staff revealed that the resident's behavior was not consistently documented or addressed. Staff reported that the resident was often verbally abusive, refused medications, and exhibited physical aggression. Despite these reports, there was no evidence of a coordinated effort to reassess the resident's condition or update the care plan. The facility's failure to comprehensively assess and manage the resident's behavior created an immediate jeopardy situation, which was identified on 4/24/24 and removed on 4/25/24, although the deficient practice continued at a severity/scope level of E (potential for harm/pattern).
Failure to Notify POA of New Treatment Orders
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) when a new treatment was ordered. Specifically, the POA was not informed when a complete blood count (CBC) and urinalysis (UA) were ordered for the resident on April 7, 2024. The resident, who has diagnoses including Alzheimer's disease, depression, anxiety disorder, and dementia, had a severe impairment as indicated by a BIMS score of 7. The resident's POA was activated on April 27, 2022, and should have been notified according to the facility's policy on changes in the resident's condition. The deficiency was identified through interviews and record reviews. The nurse's note documented the order for the CBC and UA, but there was no record of the POA being notified. When contacted by the surveyor, the POA confirmed that they were not informed about the CBC and only learned about the UA after the fact. The Assistant Director of Nursing (ADON) was unable to provide any information regarding the notification to the POA, confirming the lapse in communication and adherence to the facility's policy.
Failure to Monitor and Care Plan for Resident's Fracture and Toe Injury
Penalty
Summary
The facility failed to ensure quality care for a resident who sustained a fracture of the left forearm after hitting her elbow on the headboard of the bed. The facility did not consistently monitor the resident's left arm and did not implement a care plan regarding the fracture. Additionally, the resident had a concern with the right middle toe, which was documented as being purple and painful, but there was no monitoring of this toe. The resident's diagnoses included Alzheimer's disease, depression, anxiety disorder, and dementia, with a BIMS score indicating severe impairment. The incident began when the resident hurt her elbow while flailing her arms during a catheterization attempt. Despite the resident's complaints of pain and visible symptoms such as swelling and discoloration, the facility's response was limited to administering Tylenol and applying ice. The resident's care plan was not updated to reflect the new injury, and there was no consistent monitoring of the left arm's condition or the right middle toe. The facility's 24-hour sheets from the relevant period did not document any monitoring of these issues. The resident's condition was noted by various staff members, including LPNs, RNs, and the DON, but no comprehensive care plan was developed. The resident was eventually discharged to the hospital, where the emergency department noted old bruising and swelling of the left forearm. The facility's failure to revise the care plan and consistently monitor the resident's injuries was confirmed through interviews with the RN/ADON and the physician, who indicated that the resident had refused some interventions but was still using the injured arm to propel her wheelchair.
Failure to Provide Timely Therapy Services
Penalty
Summary
The facility did not ensure therapy services were provided in a timely manner for a resident (R2) who was readmitted to the facility. R2 had physician orders for evaluation and treatment by speech, physical, and occupational therapy, but these evaluations were not conducted. The facility's Rehabilitation Services Screening Policy and Procedure mandates that on-demand screens should be completed the same day the request is received or no later than 48 hours during regular therapy business hours. However, R2 was not evaluated or screened for therapy services as required by the physician's orders and the facility's policy. R2 was admitted with multiple diagnoses, including Hypertensive Heart Disease, Type 2 Diabetes Mellitus, Anemia, Chronic Atrial Fibrillation, and Vascular Dementia. Upon readmission from the hospital, R2's condition had declined, requiring increased assistance for daily activities. Despite this, the facility failed to conduct the necessary therapy evaluations. The surveyor noted that R2's comprehensive care plan included interventions for therapy evaluation and treatment, but these were not followed. The surveyor found that R2 had a significant decline in bed mobility and required more assistance after returning from the hospital. The facility's policy also required quarterly screenings for therapy needs, which were not conducted for R2. The Director of Nursing and the Nursing Home Administrator acknowledged the oversight but did not provide further information or documentation to show that the required evaluations had been completed. This failure to follow physician orders and facility policy resulted in a deficiency in providing timely therapy services to R2.
Failure to Inspect and Maintain Bed Frames and Rails
Penalty
Summary
The facility failed to ensure that bed frames and bed rails were inspected and maintained according to the Manufacturer's Instructions for Use (MIFU), which posed a risk of bed malfunction or resident injury. This deficiency was identified for four residents, and it had the potential to affect all 94 residents using beds in the facility. The facility's policy required regular inspections of bed frames, mattresses, and bed rails to identify and avoid areas of possible entrapment, but these inspections were not documented as required. The Maintenance Director was responsible for keeping records of bed inspections and maintenance, but during interviews, it was revealed that there was no documentation of bed rail inspections. The Maintenance Director admitted to only inspecting unoccupied beds and not documenting inspections in the TELS system for occupied beds. This lack of documentation and inspection of occupied beds was a significant oversight, as the facility's policy and the manufacturer's instructions required thorough and regular inspections. The manufacturer's instructions for the Joerns Bed Frames UltraCare XT and EasyCare Bed Platform Model ECS specified monthly inspections for loose bolts, nuts, pins, and other retaining hardware, as well as visual inspections for any damage. However, these inspections were not conducted or documented as required, leading to the deficiency. The Maintenance Director's failure to follow the established maintenance and inspection schedule contributed to the facility's non-compliance with safety standards.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled and stored according to their policy and procedures, as observed during a survey. Specifically, two out of four medication carts and one out of three medication rooms were found to have medications that were either expired or lacked proper labeling. Medications such as ophthalmic and liquid medications were found without open dates, and several expired medications were not removed from stock. This included expired cranberry supplements, acetaminophen suppositories, calcium supplements, and other medications found in the first-floor medication room. Additionally, the surveyor observed that the first-floor medication cart contained open medications without listed open dates, including eye drops and a nystatin suspension bottle. The second-floor medication cart also had similar issues, with open eye drops and other liquid medications lacking open dates. Furthermore, the second-floor cart was noted to be unclean, with medication bottles unbagged and stuck to the drawer with a sticky substance. These observations were shared with the Nursing Home Administrator, but no additional information regarding the facility's Medication Storage policy was provided at that time.
Failure to Permit Resident's Return After Therapeutic Leave
Penalty
Summary
The facility did not ensure that a resident who went out on therapeutic leave was able to return to the facility, as required by their written policy. The resident, who was cognitively intact and had a BIMS score of 15, was initially admitted to the facility and later switched to Medicaid as the primary payor source. Despite having an active discharge plan, the resident expressed a desire to stay at the facility until her husband found a new apartment for them. The facility's social services and business office manager communicated with the resident and her husband about the potential for private pay if Medicaid authorization was not obtained, and the resident agreed to stay at the facility under these conditions. However, the resident went out on a therapeutic leave with her husband and did not return as planned, leading to multiple attempts by the facility to arrange her return, which were unsuccessful due to lack of communication from the resident and her husband. The facility ultimately decided not to allow the resident to return after she failed to come back by a specified date and time, as directed by the Corporate Vice President of Success. The facility did not offer a bed hold to the resident and considered her absence as a self-discharge, despite the lack of a formal discharge plan and the resident's unstable housing situation. The facility's administrator acknowledged the absence of a policy regarding bed hold or therapeutic leave and admitted that the situation was not handled with proper notice or consideration of the resident's circumstances.
Failure to Attempt Alternatives and Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that alternatives to bed rails were attempted before their use and did not document the reasons for the failure of these alternatives. This deficiency was observed in two residents, who were not informed of the risks and benefits associated with bed rail use, nor was informed consent obtained prior to installation. The facility's policy requires that alternatives be attempted and documented if they fail, but this was not adhered to in the cases reviewed. For Resident 47, the facility did not document any attempted alternatives to bed rails or why any alternatives failed. The resident, who has moderate cognitive impairment and medical conditions including hemiplegia and hemiparesis, was observed using bilateral assist bars. However, there was no evidence that the resident was adequately informed about the risks and benefits of using these bars, as required by the facility's policy. Similarly, Resident 53, who also has moderate cognitive impairment and medical conditions such as bilateral shoulder muscle wasting and type II diabetes, was found to have an assist rail on the bed without any documented attempts of alternatives or informed consent. The resident was not advised of the risks and benefits of the bed rails, and the facility did not document any failure of alternatives, contrary to their policy.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to six residents and their representatives, as required by policy and regulation. These notices should have included the reason for transfer, the place of transfer, and information on how to appeal the transfer. The deficiency was identified during a review of records, interviews, and policy examination, revealing that the facility did not adhere to its own policy of notifying residents and their representatives in writing, especially in cases of emergent hospital transfers. For Resident 47, the facility's records showed multiple hospital transfers due to medical conditions such as hemiplegia, aphasia, and congestive heart failure. However, the facility only notified an unnamed person by phone, failing to provide the required written notice. Similarly, Resident 55 experienced several hospitalizations, but the facility did not provide written notices, and the resident confirmed not receiving any documentation upon return to the facility. The survey also highlighted similar deficiencies for Residents 77, 7, 1, and 391, where the facility relied on phone notifications rather than written documentation. Interviews with staff, including the Nursing Home Administrator and Director of Nursing, confirmed the lack of written notices, with the staff under the impression that phone updates sufficed. This systemic issue affected the residents' and their representatives' ability to understand and appeal the transfers, as required by regulation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 794 citations issued within 25 miles in the last 12 months — including the 21 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) |
|---|---|---|---|---|
| Wheaton Franciscan Hc - Terrace At St Francis | 1.5 mi | ★★★★★ | 38 | 0 |
| Complete Care At Southpointe | 1.6 mi | ★★★★★ | 19 | 0 |
| Aria At Mitchell Manor | 1.7 mi | ★★★★★ | 3 | 0 |
| Greendale Park Nursing And Rehab | 2.3 mi | ★★★★★ | 42 | 0 |
| St Ann Health And Rehabilitation Center | 2.3 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.