Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waters Edge Health And Rehabilitation Center during CMS and state inspections, most recent first.
Multiple incidents of resident-to-resident abuse occurred on the dementia unit, including inappropriate sexual contact, physical aggression, and verbal threats. Despite known behavioral histories and repeated staff warnings, the facility did not consistently implement or maintain effective supervision or interventions, resulting in repeated abuse and injuries among residents with severe cognitive impairments. Documentation and staff interviews revealed that the facility was aware of the risks but failed to take adequate steps to prevent further incidents.
Multiple allegations of abuse, including sexual and physical incidents involving residents with severe cognitive impairment, were not timely reported or thoroughly investigated by facility staff and administration. Required notifications to the State Survey Agency and law enforcement were not made, and protective measures were inconsistently implemented, leaving residents at risk. Staff observations and reports were often dismissed or inadequately documented, and care plans were not updated to address ongoing risks.
Administration failed to implement abuse prevention procedures and did not thoroughly investigate or report multiple incidents of physical aggression and inappropriate sexual contact between residents. Staff repeatedly informed administration of escalating behaviors, but incidents were dismissed or not reported to the State Survey Agency as required. A resident with severe cognitive impairment and a history of trauma was not protected from sexual abuse, and staff reported a culture of fear and retaliation, insufficient training, and inadequate supervision on the dementia unit.
A resident with advanced dementia and behavioral symptoms did not receive a comprehensive assessment or individualized, person-centered interventions. Staff failed to consistently document and monitor behaviors, and the care plan lacked specific strategies to address aggression, resistance to care, and inappropriate conduct. Inadequate supervision and a lack of specialized dementia training for staff contributed to ongoing incidents and insufficient care.
A resident with depression, delusions, hallucinations, and impaired decision-making did not receive documented psychosocial support or advocacy related to a pending guardianship process. The resident repeatedly said the resident did not want to stay, felt trapped, and believed items were being stolen, then became agitated when court papers were served, with staff documenting hallucinations, delusions, confusion, and aggression. Social work did not document assistance with the guardianship process or contact with the GAL, and the resident later left AMA without documented access to medications or physician orders.
Surveyors found that the facility did not maintain an effective pest control program, resulting in persistent fly infestations in resident rooms, hallways, and near the kitchen. Multiple residents and staff reported ongoing problems with flies, especially when food or garbage was present, and staff relied on manual methods like fly swatters and bug zappers instead of contacting the pest control company as required by facility policy.
Surveyors found that the facility did not consistently provide a clean and homelike environment, as multiple residents and staff reported that rooms were not cleaned daily and garbage was not regularly emptied, resulting in odors and visible stains. Grievance records confirmed ongoing issues with room cleanliness, and staff interviews revealed that both housekeeping and nursing staff were unable to maintain required cleaning standards due to inconsistent practices and lack of documentation.
The facility did not report multiple allegations of abuse, neglect, and resident-to-resident altercations to the State Survey Agency within required timeframes. In several cases, staff observed or were informed of incidents involving physical and verbal abuse, sexual abuse, and threats among residents, but the NHA either did not report these incidents or submitted reports late, often relying on informal, unsigned staff statements or personal judgment that the events did not occur as described.
Privacy and Confidentiality Breaches: An unattended medication cart computer screen displayed a resident’s PHI in the hallway, an LPN performed enteral tube care and medication administration for a resident with the room door open and curtain not drawn, and a sheet with personal information for about 11 residents was left on top of a medication cart in plain view.
Missing Written Transfer, Bed-Hold, and Ombudsman Notifications: Multiple residents were transferred to the hospital or discharged AMA without proper written transfer/bed-hold notices being provided to the resident or representative. The forms lacked the bed-hold reserve rate and required contact information for the State Survey Agency, LTC Ombudsman, and protection-and-advocacy agency, and the facility did not document Ombudsman notification. Several records reflected only verbal consent from staff or family/guardian rather than a signed written notice.
Medication Labeling and Storage Deficiencies: Surveyors observed multiple unlabeled or undated medications and biologicals across several med carts, including an insulin pen used for a resident, eye drops, loose pills, multiple insulin pens stored together without proper separation or resident labeling, and blood glucose test strips without open dates. Staff acknowledged that insulin pens and eye drops should be dated when opened, and the DON stated insulin pens should be separated and labeled, but glucose test strips in use could not be tracked by open date.
Staff failed to follow infection control practices for multiple residents. An LPN did not perform hand hygiene before preparing medications, and staff provided G-tube medication administration and tube feeding to residents on EBP while wearing gloves only and no gown. An RN did not disinfect a glucometer between residents for the required contact time. A resident’s catheter drainage bag was also observed uncovered and on the floor or bed frame, and another resident on contact/EBP precautions received care without consistent PPE use or hand hygiene.
The facility failed to prevent accidents and supervise residents adequately when multiple residents experienced falls and repeated unsafe events. A resident with high fall risk fell from bed during care when the bed was unlocked and sustained a forehead laceration requiring sutures, while another resident with severe cognitive and behavioral impairment had numerous falls and episodes of putting self on the floor, with several incomplete or missing fall investigations, missing RN assessments, and inconsistent implementation of ordered fall precautions such as wheelchair supports, locked equipment, and approach precautions.
A resident with intellectual/developmental disabilities and mental illness did not receive the specialized services recommended by a PASARR Level II evaluation. The facility's care plan lacked person-centered interventions and did not involve a QIDP or provide targeted therapies as outlined in the PASARR report. Staff were not trained or aware of specialized services, and there was insufficient monitoring of behaviors related to psychotropic medication use.
Three residents did not receive necessary care and treatment as ordered or according to their preferences, including failure to process a urinalysis and wound culture for a resident with infection symptoms, lack of timely assessment and treatment for another resident's surgical wounds, and improper use of double incontinent briefs for a dependent resident without care plan direction.
Three residents with pressure injuries did not receive timely or appropriate assessment, treatment, or care planning. One resident's sacral pressure injury was not assessed or treated for several days after admission, and staff were unaware of the wound. Another resident's pressure injury was incorrectly staged and not treated for three days, with no care plan updates when the wound worsened. A third resident developed a stage 3 pressure injury from a palm guard, with no interventions in place before or after the injury, and no comprehensive assessment or therapy referral documented.
Misappropriation of a resident's cell phone occurred when a housekeeper entered the resident's room while the resident was hospitalized and took the phone without consent. The resident had chronic respiratory failure, DM2, a tracheostomy, encephalopathy, and moderately impaired cognition with a BIMS score of 12. Family later reported the phone missing, records showed the phone number was still in use, and surveillance linked the housekeeper to the room access and the phone account being logged out.
A facility failed to keep 2 residents’ care plans accurate. One resident with a stage 4 sacral pressure injury and a heel wound had an air mattress and a blue floor mat in use, but the care plan did not document the air mattress or specify when and where to use the mat. Another resident with a feeding tube and guardian-approved pleasure feedings of scrambled eggs twice daily had physician orders and risk/benefit documentation, but the comprehensive care plan and CNA Kardex were not updated to reflect the change.
A resident with anxiety, COPD, and HTN had an oxygen care plan and MD order for 2 L/min via nasal cannula, but the surveyor observed the oxygen flowing at 4 L/min on two occasions while the resident was in bed with the cannula in place.
A resident receiving dialysis did not have MD orders reentered after a hospitalization, including orders for access type and location, dialysis schedule, nephrologist contact information, and AV fistula monitoring for bruit and thrill every shift and before/after dialysis. Staff interviews confirmed the orders had been present before the hospitalization but were not restored when the resident returned, despite the resident’s dialysis care plan calling for ongoing AV fistula checks.
Medication Error Rate Exceeded Threshold: Surveyors found 2 medication errors in 25 opportunities, resulting in an 8% error rate. A resident’s Pantoprazole was not available during the med pass, and an LPN administered Advair without having the resident rinse and spit afterward, despite the facility policy and the physician order requiring it.
Failure to document and offer flu and pneumococcal vaccines for a resident with chronic respiratory failure, CHF, and CKD. The EMR did not show that the resident was offered, received, or declined the influenza vaccine, and there was no clear documentation that the pneumococcal vaccine was assessed or offered per policy. The UM stated the resident declined to provide a SSN to check the WIR and said the resident refused immunizations, but the handwritten notes provided referenced COVID-19 consent and did not document flu vaccination.
Missing COVID-19 Immunization Documentation in Resident EMRs: The facility failed to document whether three residents were offered, received, or declined the COVID-19 vaccine. The residents had significant medical histories, including trach, encephalopathy, diabetes, epilepsy, dementia, dysphagia, CHF, and CKD. The UM stated she reviews immunization records, offers the vaccine, and documents education or refusals in the EMR, but the surveyor found no EMR documentation for the residents, and handwritten notes provided later were not in the EMRs.
A resident with multiple diagnoses, intact cognition, and documented need for assistance with bed mobility was not promptly boosted and repositioned when she requested help. A CNA said she could not assist alone and left to get help, but the resident remained in the same position for an extended period, became tearful, and said her back hurt and she could not eat. An LPN later assisted with repositioning, after which the resident said she felt better but no longer wanted lunch; CNA documentation incorrectly recorded that she ate 75% of the meal.
Missing physician order for resident code status: The facility did not follow its code status documentation procedure for a resident with a legal guardian. Although the guardian signed for full code status and staff said they had unit information on code status, surveyors found no current physician order or EMR entry documenting the resident’s code status. An LPN confirmed the EMR did not list a current code status, and the SWA stated she did not maintain code status in the EMR.
Pharmacist MRR irregularities were not properly acknowledged or acted upon for two residents. One resident with multiple chronic conditions had PRN alprazolam use flagged because it exceeded the 14-day PRN psychotropic limit, but the physician response was not documented until later. Another resident with autism, intellectual disability, epilepsy, mood disorder, anxiety, and a gastrostomy had multiple pharmacist concerns involving PRN lorazepam and temazepam, duplicate antipsychotics, high-dose quetiapine, and later valproate, lorazepam, olanzapine, and temazepam orders; the forms showed no checked response options from the prescriber.
Two residents did not receive timely therapy services after physician orders for PT/OT evaluation and treatment. One resident with severe cognitive impairment, falls, and behavioral issues had OT/PT screens completed well after the order date, while another resident with trach dependence, quadriplegia, stroke, and other complex conditions did not start PT/OT until weeks after admission despite MD documentation that therapy was needed. Therapy leadership stated evaluations are typically completed within a few days of an order and acknowledged the delay.
A newly graduated LPN, still in orientation, administered an incorrect dose of insulin to a resident with type II diabetes due to lack of documented orientation and competency check-off. The LPN was left to work independently after a staff call-off, despite facility policies requiring competency verification before independent assignments.
A resident with severe cognitive impairment and type II diabetes was given 15 units of insulin lispro instead of the prescribed 4 units, due to failure to follow physician orders. The error was recognized by an LPN shortly after administration, and the resident was monitored for adverse effects, with no negative outcomes observed.
Two LPNs failed to wear gowns while performing wound care for a resident on Enhanced Barrier Precautions, despite facility policy and posted signage requiring gown and glove use for high-contact care activities involving wounds and invasive devices. The resident had multiple medical conditions and devices, and the omission was acknowledged by staff after the procedure.
The facility did not maintain an adequate supply of clean linens in multiple linen closets, as reported by several residents and confirmed by staff interviews and direct observation. Residents experienced delays in showers and personal care, with some stockpiling linens to avoid shortages. CNAs and an LPN reported having to wait for laundry deliveries, especially in the mornings and on weekends, while the Laundry Manager and DON were unaware of or lacked policies to address the issue.
A resident with a history of traumatic brain injury and significant cognitive impairment fell from bed while receiving care from a CNA who did not follow the care plan requiring assistance from two staff members. This resulted in the resident sustaining a broken hip and a laceration requiring staples. The facility's policy on supervision was not adhered to, leading to the accident.
A facility failed to report an alleged care violation to the State Agency within the required timeframe. A resident's family raised concerns about incontinence care, but the facility submitted the investigation report late. The resident, with multiple health issues, is dependent on staff for care. Despite documentation of care provided, the family alleged no care was given on a specific day. The facility's investigation found no concerns.
The facility did not ensure a charge nurse was assigned for each shift, affecting all 95 residents. Staffing schedules from January to March and July 2024 lacked designation of a charge nurse and did not specify if nurses were RNs or LPNs. The scheduler and DON relied on personal knowledge rather than documentation. A subsequent schedule review showed proper designation of charge nurses.
The facility did not ensure food was prepared according to standardized recipes for residents on a pureed diet. Cook-C was observed preparing pureed Salisbury steak and carrots without measuring ingredients or following recipes, contrary to facility policy. The Food Service Director confirmed the requirement to follow recipes, but a recipe for pureed carrots was not available at the time.
A resident with Alzheimer's and Dementia elected hospice services, but the facility failed to complete a timely Significant Change MDS. The MDS Coordinator acknowledged the delay, and the surveyor noted incomplete sections over a month later, raising concerns with the DON.
A resident with dementia experienced significant hearing difficulties, yet the facility failed to arrange timely audiology services. Despite orders for an audiology consult in early 2024, the appointment was not arranged until months later, after the surveyor's intervention. The resident's hearing issues were documented, but the necessary consult was delayed.
A resident with Huntington's disease and muscle weakness was not provided with the prescribed hand splint to prevent further decline in range of motion. Observations showed the resident's hand was not splinted as required, and staff interviews revealed confusion about the splint's location and application. Despite the care plan's directives, the resident did not receive the necessary treatment.
A resident with an indwelling catheter did not receive appropriate care to prevent urinary tract infections, as observed by a surveyor. The CNA failed to follow the facility's catheter care policy by using the same washcloth to clean different areas, including the urethral meatus and catheter tubing. The resident, with a history of urosepsis and recent positive urine culture, was at risk due to this improper care.
Two residents experienced deficiencies in enteral feeding management, with discrepancies between feeding orders and actual administration leading to significant weight loss and potential dehydration. The facility failed to ensure accurate documentation and communication between nursing staff and the dietitian, resulting in residents not receiving the correct nutrition and hydration.
A resident was observed lying on a bed with a fitted sheet that did not cover the entire mattress, leading to direct contact with the mattress. Despite the availability of bariatric fitted sheets, staff failed to use them correctly, resulting in a deficiency in providing a safe and comfortable environment. The issue was reported to the NHA and DON, but no further information was provided.
A resident with a history of traumatic brain injury and quadriplegia developed blisters on their left hand due to improper use of hand splints. The facility failed to update the care plan and treatment administration record (TAR) to reflect necessary changes in the resident's treatment, leading to continued application of the splints despite recommendations to hold them until the blisters healed. This deficiency was identified during a surveyor's investigation.
A resident with schizophrenia and dysphagia was observed eating alone without supervision, contrary to their care plan requiring constant supervision during meals to prevent choking. Staff interviews revealed inconsistencies in understanding and implementing the resident's supervision needs, with the CNA checking periodically rather than providing constant oversight. The DON acknowledged the usual practice of supervision, but it was not followed during the surveyor's visit.
The facility failed to accurately document PASRR evaluations in the MDS assessments for five residents with mental disorders. Despite having completed PASRR Level I and II evaluations, the MDS assessments incorrectly indicated 'no' to the presence of serious mental illness or related conditions. The MDS Coordinator attributed the error to a lack of scanned records and suggested that Social Services should handle the relevant MDS section.
The facility failed to prevent and manage pressure injuries for three residents, leading to the development and worsening of pressure injuries. One resident developed an unstageable pressure injury due to a lack of a skin integrity care plan and inadequate monitoring. Another resident's pressure injury was not assessed in a timely manner, and a third resident's air mattress was improperly set, causing harm. The facility did not adhere to its policy on pressure injury prevention and management, resulting in Immediate Jeopardy.
A resident in a LTC facility developed urinary tract infections and bowel incontinence due to inadequate catheter care and lack of a bowel management plan. Despite being assessed as continent upon admission, the resident became incontinent, and there was no comprehensive care plan or physician orders for catheter care. Facility staff failed to document and communicate the resident's bowel and catheter care needs, leading to a decline in the resident's condition.
The facility failed to promptly address grievances and recommendations from Resident Council meetings, affecting all 98 residents. Grievance logs lacked essential details, and residents reported issues such as delays in food service, staff using earbuds during care, and inadequate laundry and housekeeping services. Interviews revealed ineffective grievance management and communication, leading to ongoing resident dissatisfaction.
The facility failed to provide notice of resident rights and services prior to or upon admission for all residents reviewed. The deficiency was due to issues with transitioning from paper to digital admission agreements and obtaining signatures, especially for residents admitted after hours or on weekends. The facility's policy requires signed agreements, but none of the residents had them at the time of admission. The Nursing Home Administrator acknowledged the issue and stated that the facility was aware of the problem.
The facility failed to report incidents of abuse, drug diversion, and misappropriation within the required timeframes, affecting several residents. A resident with dementia was involved in an unreported abuse allegation, while discrepancies in controlled substances were not promptly reported. Additionally, a resident accused staff of misappropriation and assault, but the incident was reported late to the State agency.
The facility did not adequately safeguard confidential medical records, affecting up to 30 current residents. Medical records were stored in open cardboard boxes on the floor under a fire sprinkler, risking water damage. Medical Records-OO acknowledged the risk and the need for proper storage. The issue was reported to the NHA and DON, but no explanation was provided for the oversight.
Failure to Prevent Resident-to-Resident Abuse on Dementia Unit
Penalty
Summary
The facility failed to protect residents from verbal, physical, and sexual abuse, particularly on the dementia unit, where 12 separate incidents of resident-to-resident abuse were identified. Multiple residents with severe cognitive impairments and behavioral issues were involved in repeated altercations, including inappropriate sexual contact, physical aggression, and verbal threats. Despite documented histories of aggressive and inappropriate behaviors, the facility did not consistently implement or maintain effective supervision or interventions to prevent further incidents. For example, a resident with a known history of sexually inappropriate behavior and aggression was only placed on increased supervision temporarily after incidents, but this was not sustained, allowing further abuse to occur. Specific incidents included a resident being observed touching another resident inappropriately, repeated physical altercations resulting in injuries such as skin tears and scratches, and verbal abuse and threats. Staff interviews and record reviews revealed that the facility was aware of the risks posed by certain residents but failed to take adequate steps to separate residents or provide continuous supervision as required by their own policies. In several cases, staff reported escalating behaviors and prior warnings, but interventions such as one-to-one monitoring were either not implemented or not maintained, leading to repeated incidents. The facility's documentation and staff statements also showed inconsistencies and a lack of thorough investigation into reported incidents. Some staff statements were unsigned, and there were discrepancies between staff accounts and administrative conclusions. In several cases, administration minimized or dismissed the severity of incidents, citing brief durations or lack of direct observation, despite multiple staff and resident reports to the contrary. The failure to protect residents from abuse and to follow established policies resulted in a finding of immediate jeopardy, affecting all residents on the dementia unit.
Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to timely report and thoroughly investigate multiple allegations of abuse, including sexual, physical, and verbal abuse, involving residents with severe cognitive impairments. Several incidents were not reported to the State Survey Agency within the required timeframes, and law enforcement was not notified in cases of alleged sexual assault. The facility also did not ensure that residents were protected from further potential abuse during the investigation period, as required by their own policies. Staff interviews and record reviews revealed that supervision and interventions for residents with known aggressive or inappropriate behaviors were inconsistently implemented and not maintained to prevent recurrence. One resident with a history of dementia, agitation, and aggressive behaviors was involved in repeated incidents of physical and sexual abuse toward other residents. Despite documented observations and staff reports of inappropriate touching and physical altercations, the facility administration often dismissed these allegations, citing insufficient evidence or the brevity of the incidents as reasons for not reporting or investigating further. Staff statements were inconsistently collected, often unsigned, and the cognitive status of the residents involved was not adequately considered during interviews. In some cases, care plans were not updated to reflect new risks or to implement protective measures for vulnerable residents. The facility's failure to act in accordance with its abuse prevention policies resulted in a pattern of unreported and uninvestigated abuse allegations, leaving residents at continued risk. The lack of immediate protective actions, incomplete documentation, and disregard for staff observations contributed to the finding of Immediate Jeopardy, affecting all residents on the dementia unit. The deficient practice persisted as the facility continued to implement its action plan, but the initial failures were not mitigated during the period under review.
Failure to Protect Residents from Abuse and Inadequate Incident Reporting
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Administration did not implement procedures based on the facility's Abuse, Neglect, and Exploitation policy, despite being aware of multiple residents with unpredictable and aggressive behaviors. Staff repeatedly informed administration about ongoing physical aggression, sexual behaviors, and escalating incidents among residents, but these reports were not acted upon appropriately. Several incidents of resident-to-resident altercations, physical assaults, and inappropriate sexual contact were not reported to the State Survey Agency within required timeframes and were not thoroughly investigated. Documentation and staff statements regarding these incidents were inconsistent, and administration often dismissed allegations based on their own review of camera footage or by questioning the validity of staff reports. Residents with significant behavioral health needs, including those with histories of physical and sexual assault, were not adequately protected. For example, a resident with severely impaired cognitive skills and limited mobility, who had a history of trauma, was subjected to inappropriate sexual contact by another resident known for sexually inappropriate and aggressive behaviors. Despite care plans and trauma assessments indicating the need for increased supervision and interventions, the facility did not implement or maintain adequate measures to prevent further abuse. Staff reported being unable to provide 1:1 supervision due to staffing shortages and felt unsupported by administration, who did not respond to or investigate incidents as required. A pervasive culture of fear and retaliation was reported among staff, who expressed concerns about being terminated or suspended for reporting abuse or cooperating with surveyors. Staff described the dementia unit as chaotic, with insufficient training and high turnover, and reported that administration discouraged open communication and reporting of incidents. Staff statements were often collected by administration in a manner that did not allow for verification or accuracy, and some staff were disciplined or terminated for not aligning with administration's narrative. These failures resulted in multiple deficiencies, including findings of Immediate Jeopardy, and affected the safety and well-being of all residents on the dementia unit.
Removal Plan
- Residents reviewed for proper placement on Dementia Unit. Residents identified as needing placement with active efforts for discharge to proper community placement.
- Admission team to conduct additional review for possible placement on Dementia Unit to ensure resident aligns with unit's goals and bed availability is appropriate.
- Employee Feedback form initiated to solicit feedback and solutions when staff see an opportunity and desire to remain anonymous or not.
- Facility initiated new tool from the Center of Excellence Post-Behavior Root Cause Analysis (RCA) form, providing additional insight to residents when behaviors occur. This tool utilizes a team approach (huddle) to gain knowledge of behaviors/events. Facility Staff completed this tool for those residents with known behaviors on the dementia unit to further care plan any additional interventions that may reduce resident to resident interactions and behaviors.
- Regional Human Resources Director initiated interviews with current staff.
- Administrator of Sister Facility, Social Services background, provided remote review of focused Dementia Unit residents to provide additional suggestions and feedback for interventions, and providing on-site support to assist efforts.
- Current Nursing Home Administrator was placed on administrative leave by Director of Operations.
- Re-Education by Director of Operations to Interdisciplinary Team (Dementia Unit focused) to include use of Post-Behavior Root Cause Analysis (RCA) Form.
- Re-Education by IDT to Facility Staff to include use of Employee Feedback Form. Facility Staff that have not yet received the re-education, and required to complete, will have these items completed prior to their next scheduled shift.
- Monitor: Review of Post-Behavior Root Cause (RCA) completion for behaviors.
- Use of Employee Feedback Form reviewed upon receipt.
- Ad Hoc QAPI held to discuss the above actions taken.
Failure to Provide Person-Centered Dementia Care and Behavioral Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with unspecified dementia, agitation, depression, anxiety disorder, and visual hallucinations. The resident exhibited significant behavioral symptoms, including aggression, resistance to care, verbal and physical altercations with staff and other residents, and sexually inappropriate behaviors. Despite these ongoing issues, the facility did not conduct a comprehensive assessment to identify the root causes or triggers of the resident's behaviors, nor did it develop or implement a person-centered care plan with individualized, non-pharmacological interventions. The care plan lacked specific interventions tailored to the resident's needs, and staff were not provided with adequate guidance or training to manage the resident's complex behaviors. Documentation in the Treatment Administration Records (TAR) was inconsistent and incomplete, with staff failing to accurately monitor or record the resident's behaviors as required. Staff interviews revealed a lack of understanding regarding the resident's hallucinations and behavioral symptoms, and there was no evidence of a root cause analysis being performed to address the behavioral changes. The facility's approach to supervision was insufficient, as 1:1 supervision was expected to be provided by staff already assigned to the unit, rather than by a dedicated staff member, resulting in inadequate monitoring and intervention during behavioral incidents. Additionally, staff on the dementia unit had not received specialized dementia training, and there was high turnover among staff, further impacting the quality of care. Multiple staff members reported feeling unsupported and overwhelmed, with insufficient resources to provide the required supervision and care. The facility did not investigate incidents or provide staff with the necessary tools to implement person-centered interventions, and the care plan failed to identify or address environmental triggers that may have contributed to the resident's behavioral expressions.
Failure to Provide Medically Related Social Services for a Distressed Resident
Penalty
Summary
The facility did not ensure that a resident with hemiplegia, depression, delusional disorder, visual hallucinations, and moderate impairment in daily decision-making received medically related social services to address emotional distress and psychosocial needs. The resident’s MDS documented hallucinations, delusions, verbal and physical behaviors, and rejection of care. The care plan identified the resident as an elopement risk and noted expressions related to hallucinations and paranoia, but the social work record did not document psychosocial support or advocacy related to the resident’s pending guardianship process. The resident repeatedly expressed distress about being at the facility, stating to the surveyor that the resident did not want to be there, felt trapped, and believed people were stealing. The resident had also been involved in two resident-to-resident altercations and was reported by staff to barricade the room door so others would not wander in. On the day court papers were served, the resident became agitated after police delivered guardianship documents, denied needing a guardian, and reported that belongings had been stolen. Staff documented acute hallucinations, delusions, confusion, agitation, and aggression, and the resident was observed shouting, swearing, and attempting to approach another resident. Social services documentation showed that the social worker assistant did not assist with the guardianship process, did not contact the guardian ad litem, and did not provide documentation of psychosocial support for the resident’s distress. APS and facility staff described the situation as chaotic, and APS stated the resident appeared clearly in distress and that the social worker assistant could have done more to advocate and assist. After the agitation escalated, the resident chose to leave the facility AMA, signed the AMA paperwork, and left without documented access to the resident’s medications or copies of physician orders. The resident’s departure occurred after the resident had expressed distress, paranoia, and a desire not to remain at the facility.
Deficient Pest Control Program Resulting in Persistent Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to address the presence of flies throughout the building, as evidenced by observations, interviews, and record reviews. Multiple residents with intact cognition reported ongoing issues with flies in their rooms and common areas, particularly when food was present or garbage was not promptly removed. Surveyors directly observed flies in resident rooms, hallways, and near the kitchen, as well as fly swatters kept by residents' beds for personal use. Staff interviews confirmed that the fly problem was persistent and had been reported to management multiple times, but staff were unsure if any effective action had been taken. The facility's pest control policy required the use of various methods, including engagement with an outside pest service, to control seasonal pests such as flies. However, maintenance staff indicated that the pest control company was not contacted regarding the current fly issue, as they believed the number of flies was typical for the facility. Instead, staff relied on manual methods such as using fly swatters and bug zappers at main exits. The issue was particularly pronounced in areas near exterior doors and dumpsters, and both residents and staff expressed frustration with the ongoing presence of flies despite repeated reports and complaints.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as required. Multiple residents reported that their rooms were not cleaned daily, and that garbage was not always emptied, resulting in unpleasant odors. Observations confirmed these reports, with surveyors noting a urine odor in one resident's room, a dried yellow stain on another resident's bed sheet, and full garbage containers. Residents stated that while they sometimes notified staff about the lack of cleaning, the response was inconsistent and did not ensure regular cleaning as per facility policy. Interviews with facility staff, including a housekeeper, LPN, and CNA, corroborated the residents' accounts. Staff acknowledged that housekeeping did not always clean resident rooms daily, and that nursing staff sometimes had to clean up messes themselves. The housekeeper explained that while daily cleaning should include emptying garbage, sweeping, and wiping down surfaces, this was not always completed. Deep cleaning was reportedly done monthly, but there were instances where rooms were not cleaned for several days. The housekeeper also noted that certain spills, such as body fluids over a certain amount, were not cleaned by housekeeping but left for facility staff, who could not always address them promptly. A review of facility grievance records from May to August revealed 11 grievances related to unclean rooms, with investigations confirming that rooms were not cleaned as required. The facility's housekeeping and laundry services were outsourced, and the district manager stated that daily cleaning should include disinfecting surfaces, sweeping, mopping, and cleaning bathrooms. However, there was no documentation or audit trail to verify that these tasks were consistently performed. The lack of regular cleaning and failure to maintain a homelike environment had the potential to affect all residents in the facility.
Failure to Timely Report Allegations of Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report multiple allegations of abuse, neglect, and resident-to-resident altercations to the State Survey Agency as required by its own policy and federal regulations. In several instances, staff immediately notified the Nursing Home Administrator (NHA) of alleged incidents, including physical and verbal abuse, sexual abuse, and physical threats among residents. Despite these reports, the NHA did not submit the required notifications to the State Survey Agency within the mandated timeframes, which are two hours for abuse or serious bodily injury and 24 hours for other incidents. In some cases, law enforcement was also not notified as required. Specific incidents included staff witnessing one resident repeatedly hitting another with a pillow, a resident making threatening statements, and a resident physically assaulting another, resulting in a skin tear. There were also allegations of sexual abuse, where staff observed inappropriate touching or situations suggestive of sexual misconduct. In each case, the NHA either determined that the incident did not occur as reported or relied on informal, unsigned staff statements, and therefore did not report the allegations to the State Survey Agency. The facility maintained informal 'soft files' with typed but unsigned staff statements for some incidents, while in other cases, no documentation was available. Additionally, there was an instance where the facility conducted an investigation into a resident-to-resident altercation but submitted the completed investigation to the State Agency late due to the NHA's personal emergency. The report also notes that some staff failed to immediately notify the NHA of an incident, and documentation in the electronic medical record reflected staff perceptions rather than objective facts. The NHA acknowledged responsibility for submitting facility-reported incidents but stated that, based on witness statements, the incidents did not warrant reporting.
Privacy and Confidentiality Breaches
Penalty
Summary
The facility did not ensure privacy and confidentiality for 12 of 20 residents. On 9/24/25 at 12:46 PM, R112’s protected health information was observed on an unattended, unlocked medication cart computer screen in the hallway on the second floor south wing, visible to anyone walking by. No staff were observed around the cart, and a resident in a Broda chair was sitting about 6 feet away while the screen displayed R112’s medications and the reasons for the medications. Surveyor also noted that R112 was severely impaired for cognitive skills and could not be interviewed. On 9/23/25 at 1:30 PM, an LPN was observed in R45’s room with the door open and the privacy curtain not pulled while checking the placement of R45’s enteral feeding tube, flushing the tube, administering medication through the tube, and starting tube feeding. The surveyor observed the treatment from the hallway, and R45 later stated she preferred the door closed because staff have to pull her gown up. In addition, on 9/25/25 at 11:19 AM, a 2 South sheet containing approximately 11 residents’ names and personal information, including blood pressure, vital signs, liquids received, seizure monitoring, fall risk, and no male caregivers, was observed on top of the 2 South medication cart in view of anyone passing by.
Missing Written Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility did not ensure that residents and/or their representatives were provided written transfer/discharge and bed-hold notices that included the reason for transfer/discharge, the bed-hold reserve rate, appeal-related information, and required contact information for the State Survey Agency, the Long Term Care Ombudsman, and the agency responsible for the protection and advocacy of individuals with developmental disabilities and mental disorders. The facility also did not document that the Ombudsman was notified of the transfers/discharges for the residents reviewed. R11, who had a legal guardian, was transferred to the hospital and the Transfer and Bed Hold Information form dated 8/25/25 did not contain the room reserve rate or the required agency contact information. The form stated that verbal consent to hold a bed was obtained, but there was no evidence the notice was provided in writing to the guardian. R1, who had diagnoses including diffuse traumatic brain injury, acute and chronic respiratory failure with hypoxia, protein-calorie malnutrition, tracheostomy status, neuromuscular dysfunction of bladder, anxiety disorder, chronic pain syndrome, colostomy status, contractures, convulsions, hypotension, stage 4 pressure injuries, history of pulmonary embolism, gastrostomy status, anemia, encephalopathy, history of venous thrombosis and embolism, and ESBL resistance, was hospitalized multiple times for change in condition. There was no evidence R1's mother/guardian received proper written transfer and bed-hold notices for those hospitalizations, and no evidence the Ombudsman was notified. R3, who was their own person, experienced a change in condition and was hospitalized, but the bed-hold and transfer notice was not scanned into the EMR and the facility provided a form showing only verbal consent rather than a signed written notice. R9, who had a guardian of person and estate, was hospitalized twice for increased restlessness, confusion, low oxygen saturation, and later hypoxemia, but there was no evidence the guardian received proper written notice and no evidence the Ombudsman was notified. R120 left the facility AMA, and the social worker stated the Ombudsman should be notified for AMA discharges, but the facility did not document that this occurred. R41, who had an activated POAHC, had a hospital transfer without a bed-hold or transfer notice in the record, and the later form contained only verbal consent and lacked required notice information. R90, who was hospitalized for wound care, also had no bed-hold or transfer notice in the record, and the later form again reflected only verbal consent without the required written notice information or Ombudsman notification.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, including dating when opened, for multiple medication carts observed by surveyors. During observation of medication administration, an RN prepared R129’s Novolin R insulin pen even though the pen was not dated when opened. In the front 2 South medication cart, surveyors observed a bottle of artificial tears lubricant eye drops for R2 that was marked only with a resident’s first name and was not dated when opened. In the 1 North back medication cart, surveyors observed approximately 33 small pink pills loose in the top drawer, and a purple plastic basket containing six insulin pens that were not separated and were not consistently labeled with resident names or dated when opened. The basket included a used Lyumjev insulin pen for R125 without an open date, a used Novolog flex pen without a resident name and without an open date, a used Ozempic pen with part of the pharmacy label removed, a used Lantus Solostar pen for R130 without an open date, a Lantus Solostar pen for R53, and a Humalog insulin kwikpen for R81 without an open date. Staff told surveyors that insulin pens should be dated, labeled, and separated, and the DON stated each pen should be in an individual bag with the resident’s name on it. Surveyors also observed a bottle of blood glucose test strips in the 2 North medication cart that was not labeled when opened, and loose blood glucose test strips sitting in a medication cup in the 1 South medication cart with no open date or expiration information. All OTC medications in the 1 South medication cart were also not labeled with opened dates. An RN stated she had borrowed test strips from another cart after running out, and facility staff were unable to identify when the strips were opened or expired after opening. The DON stated the facility did not have a policy regarding storage of glucose test strips.
Infection Control Failures During Medication Pass, Tube Care, Glucose Checks, and Catheter Care
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for six residents. During medication administration, an LPN did not perform hand hygiene before preparing medications for one resident and another LPN also did not perform hand hygiene before preparing medications for a second resident. The facility’s hand hygiene policy stated hand hygiene is indicated before preparing or handling medications. For two residents on Enhanced Barrier Precautions, staff did not wear the appropriate PPE during medication administration via gastrostomy tube. One LPN administered multiple crushed and prepared medications through a G tube, checked tube placement, flushed the tube between medications, and handled the resident’s bedding and gown while wearing gloves only and no gown. Another LPN similarly checked G tube placement, administered medications through the tube, and started tube feeding while wearing gloves only and no gown. The facility’s EBP policy identified feeding tubes as high-contact resident care activities requiring targeted gown and gloves. During blood glucose monitoring, an RN obtained a resident’s blood sugar and then placed the glucometer on the medication cart before using it again for another resident. The RN later wrapped the glucometer with a disinfectant wipe for one minute even though the wipe container stated a two-minute contact time for hard, nonporous surfaces. The RN stated she should probably have cleaned it before each patient. The facility’s glucometer policy stated the device must be cleaned and disinfected after each use according to manufacturer instructions. The report also documented concerns with other infection control practices. A resident with a suprapubic catheter had the drainage bag observed uncovered and lying on the floor, and later hanging on the bed frame uncovered, despite the facility policy stating catheter drainage bags will be covered at all times while in use. Another resident with a gastrostomy tube, loose stools, and Enhanced Barrier Precautions was observed receiving tube feeding and personal care while staff wore gloves but did not consistently wear gowns, and hand hygiene was not observed after glove removal. The infection preventionist also stated the resident was in contact isolation and that the wrong sign had been posted on the door.
Failure to Prevent Falls and Complete Fall Investigations
Penalty
Summary
The facility did not ensure the environment was free from accident hazards and did not provide adequate supervision to prevent falls for multiple residents. The report identifies deficiencies involving residents R60, R11, R41, and R90, with detailed findings focused on repeated falls, incomplete investigations, and failure to consistently implement or document fall-related interventions. The facility policy required fall-risk assessment, individualized interventions, post-fall review, documentation of evaluations and actions taken, witness statements when available, and care plan updates as indicated. R60, who had diagnoses including chronic kidney disease stage 3, COPD, morbid obesity, asthma, dysphagia, anxiety, major depressive disorder, hypertension, gout, GERD, and hereditary and idiopathic neuropathy, was assessed as high fall risk and had impaired lower-extremity range of motion and partial/moderate assistance needs for bed mobility. During care in bed, staff unlocked the bed and the resident fell between the bed and wall, striking her face and sustaining a laceration above the left eyebrow that required sutures. The facility documentation described the fall, EMS transfer, and hospital evaluation, but the care plan was not revised with the recommended interventions at the time of survey review, and staff education after the fall was limited to CNAs on the unit. The investigation noted the unlocked bed as an environmental factor, and the resident’s care plan and Kardex were not updated until after survey began. R11 had diagnoses including autistic disorder, repeated falls, intellectual disabilities, epilepsy, mood disorder, dementia, and anxiety, and was documented as severely impaired in daily decision-making with memory impairment and high fall risk. The resident experienced numerous falls and episodes of placing self on the floor, yet several fall packets lacked RN assessments, some lacked thorough investigations, and some had no investigation at all. Survey findings also showed fall-prevention interventions were not consistently implemented: the dycem and wedge cushion were not in the wheelchair when observed, the wheelchair was not locked during a later fall, the medication cart wheels were observed unlocked, and staff were observed pulling the resident from behind despite a care plan instruction not to approach from behind. The report also notes multiple incidents where the resident put self on the floor, with several of those occurrences lacking fall investigations.
Failure to Implement PASARR Level II Recommendations for Specialized Services
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination and evaluation report into the assessment, care planning, and transitions of care for a resident with intellectual/developmental disabilities and mental illness. The PASARR Level II report specified that the resident required an intensive, continuous treatment program called specialized services, including a thorough assessment by a qualified intellectual disabilities professional (QIDP), physical/occupational therapy, monitoring for nonverbal communication, and person-centered interventions to address behavioral disturbances. Despite these recommendations, the facility's care plan did not reflect the specific person-centered interventions or specialized services outlined in the PASARR report. The resident had a complex medical history, including autistic disorder, intellectual disabilities, epilepsy, mood and anxiety disorders, and required a gastrostomy. The care plan included some general interventions for behaviors and mood but did not address the specialized services or recommendations from the PASARR Level II, such as involvement of a QIDP, targeted therapies, or specific behavioral supports. Staff interviews revealed a lack of awareness and training regarding specialized services, and key personnel, including the psychologist, occupational therapist, and social workers, were not involved in developing or implementing a specialized care plan for the resident. Additionally, the facility did not consistently monitor or document the resident's behaviors in relation to psychotropic medication use, and there was no evidence of ongoing psychiatric evaluation or review after the initial assessment. Staff reported challenges in managing the resident's behaviors, frequent disruptive incidents, and a lack of clear guidance or interventions. The absence of a coordinated, person-centered approach as recommended by the PASARR Level II report contributed to ongoing behavioral issues and a chaotic environment on the unit.
Failure to Provide Necessary Care and Treatment According to Orders and Resident Preferences
Penalty
Summary
Three residents did not receive necessary care and treatment as ordered or according to their preferences and goals. One resident with a history of paraplegia and a chronic Foley catheter exhibited symptoms consistent with a urinary tract infection, including cold sweats, shivers, increased lethargy, and hypotension. Although a nurse practitioner ordered a urinalysis with culture, the sample was not processed, and the order was later cancelled by the Director of Nursing, who incorrectly determined the resident did not meet infection criteria. Review of the resident’s history and symptoms indicated that the criteria for catheter-associated urinary tract infection were met, and the urinalysis should not have been cancelled. Additionally, the same resident had a wound culture ordered for an infected wound, but the specimen was improperly stored in the refrigerator, resulting in the lab not processing it. A new specimen was not obtained until several days later, delaying appropriate treatment for the infection. Another resident was admitted with multiple surgical wounds to the left leg following a traumatic injury. Upon admission, there was no comprehensive assessment of the surgical incisions, and the care plan did not specify the locations or details of the wounds. Hospital discharge instructions required daily dressing changes and monitoring for drainage, but there were no corresponding orders or documentation of such care being provided until a week after admission. The first comprehensive wound assessment and appropriate treatment orders were not implemented until several days after admission, resulting in a lack of monitoring and treatment for the surgical wounds during that period. A third resident, who is severely cognitively impaired and dependent for all care, was observed during morning care to have two clean incontinent briefs placed on them by CNAs. Staff interviews revealed that double briefing is only to be done if it is part of the resident’s care plan or at the request of the resident or their representative, and this should be documented. Review of the care plan and Kardex showed no intervention directing staff to double brief this resident, indicating that care was not provided according to the resident’s plan or preferences.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice for three residents. One resident was admitted with a hospital-acquired stage 2 pressure injury to the sacrum, but did not receive a comprehensive assessment or treatment for the injury until several days after admission. Documentation was unclear regarding the staging of the wound, and there was no evidence of monitoring or treatment orders in place until days later. Staff interviews revealed a lack of awareness about the presence of the pressure injury, and the care plan and CNA care card did not specify the wound or interventions related to it. Another resident was admitted with a pressure injury that was incorrectly staged as a stage 2 when it was actually a stage 3. No treatment was initiated for three days after admission, and the care plan included incomplete instructions for interventions such as the use of barrier cream. When the wound worsened and increased in size, the treatment plan was not revised, and the same intervention was continued despite the lack of improvement. Documentation of wound care was also inconsistent, with several shifts lacking evidence that treatments were completed as ordered. A third resident developed a blister on the thumb that progressed to a stage 3 pressure injury, apparently related to the use of a palm guard. There were no interventions in place prior to the development of the injury, and after the injury occurred, the interventions implemented were not clearly defined. The care plan was not updated to reflect the new wound, and there was no documentation of a therapy referral or comprehensive assessment of the wound. These deficiencies were identified through interviews, record reviews, and observations, and were not addressed in a timely or systematic manner as required by facility policy.
Misappropriation of a Resident's Cell Phone
Penalty
Summary
The facility failed to ensure staff did not engage in misappropriation of a resident's belongings when R9's personal cell phone was taken without consent while R9 was hospitalized. R9 was admitted and later readmitted to the facility and had diagnoses including chronic respiratory failure, type 2 diabetes mellitus, tracheostomy, and encephalopathy. R9's admission MDS indicated moderately impaired cognition with a BIMS score of 12, and R9 was described as confused and forgetful at times with a guardian assisting in healthcare decisions. R9's family reported the cell phone missing, and the facility's investigation determined that housekeeper-PP entered R9's room while R9 was in the hospital and removed the phone's [NAME] card and logged the account out. Phone records showed the phone number remained in use, and the nursing home administrator reviewed surveillance showing housekeeper-PP accessed R9's room on the same day the phone account was logged out. Police were notified, and the facility self-report concluded the phone went missing while R9 was hospitalized. The housekeeper could not be located for interview.
Care plans were not updated to match resident interventions and ordered pleasure feedings
Penalty
Summary
The facility did not ensure the comprehensive care plans for 2 of 20 sampled residents were accurate and included interventions needed to implement care. R90 was admitted for wound care and had a stage 4 pressure injury on the sacrum and a pressure injury on the right heel. Surveyors observed R90 with an air mattress on the bed and a blue mat on the floor, but the care plan for pressure injury did not include the air mattress, and the falls care plan did not specify when or where to use the blue mat. The record showed a prior fall from bed with no injury, but the fall documentation did not include a blue mat as an intervention, and the DON stated the blue mat was used for the side R90 leans to in bed even though this was not documented on the care plan. R11 had a legal guardian and received nutrition through a feeding tube, but the guardian requested pleasure feedings of scrambled eggs twice daily. The RD documented that R11 remained NPO due to aspiration risk, while the Risk/Benefit Record Tool and physician orders reflected the pleasure feedings. However, R11’s comprehensive care plan was not revised to include the scrambled egg pleasure feedings, and the targeted problems were not updated to reflect the change. The Kardex still instructed CNAs that R11 was NPO, and the RD confirmed the comprehensive care plan had not been updated when the pleasure feedings were added.
Incorrect Oxygen Flow Setting
Penalty
Summary
The facility did not ensure safe and appropriate respiratory care for 1 resident receiving oxygen when the prescribed oxygen setting was not followed. R49, who was admitted with diagnoses of anxiety, COPD, and hypertension, had an oxygen therapy care plan documenting oxygen via nasal cannula at 2 liters per minute and physician orders dated 7/16/25 also specifying 2 liters per minute. However, on 9/22/25 at 9:54 a.m. and again on 9/23/25 at 7:40 a.m., the surveyor observed R49 in bed with a nasal cannula in place and the oxygen flow indicating 4 liters per minute, which did not match the ordered setting.
Missing Dialysis Orders and AV Fistula Monitoring
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required dialysis. The resident was admitted with diagnoses including stroke affecting the right dominant side and chronic kidney disease with dependence on renal dialysis, and the annual MDS documented the resident was cognitively intact and received dialysis. The resident’s dialysis care plan included interventions to assess the AV fistula in the left arm for bleeding, bruit, and thrill every shift and after dialysis, and to notify the dialysis unit if the thrill changed or was absent. After the resident returned to the facility following a hospitalization for pneumonia, the facility did not have MD orders in place for the type and location of dialysis access, the dialysis schedule, the nephrologist’s name and phone number, or the required assessment and care orders for checking bruit and thrill every shift and before and after dialysis. Survey review of the TAR showed these dialysis orders and AV site care orders had been present before the hospitalization, but they were not re-entered after the resident returned. RN and DON interviews confirmed that the resident’s dialysis MD orders were not reentered into the electronic medical record after the hospitalization.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility did not ensure the medication error rate remained below 5 percent. Surveyors identified 2 medication errors in 25 opportunities, resulting in an 8% medication error rate. One error involved R71’s Pantoprazole Sodium 20 mg, which was not available to be administered when the medication pass was observed. During the observation, LPN-MM prepared multiple medications for R71, including Metoprolol Tartrate, Gabapentin, Eliquis, Furosemide, Isosorbide Monitrate, Aspirin, Vitamin D3, Hydrocodone-Acetaminophen, and Fluticasone Propionate & Salmeterol (Advair) inhaler, and then stated that Pantoprazole Sodium was out and had been ordered in the computer with a plan to call the pharmacy later. The second error involved administration of Advair inhaler to R71 without the required rinse-and-spit afterward. The facility policy for oral inhalations stated that for steroid inhalers, the resident should be given water and instructed to rinse the mouth and spit the water back into the cup. R71’s physician order for Advair also directed staff to rinse the mouth with water and spit after each use. During the observed medication administration, LPN-MM gave Eliquis and then administered the Advair inhaler, but did not offer R71 water or instruct him to rinse and spit. Both the LPN and the DON acknowledged that residents should rinse and spit after Advair, and the DON stated medications are reordered when about five doses remain.
Failure to Document and Offer Flu and Pneumonia Vaccinations
Penalty
Summary
The facility did not ensure that 1 of 5 residents reviewed, R12, was offered or administered the influenza vaccine and/or the pneumococcal vaccine. R12 was admitted to the facility with diagnoses including chronic respiratory failure, congestive heart failure, and chronic kidney disease. Survey review of R12’s EMR did not locate documentation showing whether R12 was offered, received, or declined the influenza immunization, and the record also did not show that the pneumococcal vaccine was assessed or offered as required by facility policy. The facility’s policy required residents to be offered annual influenza immunization and to be assessed for pneumococcal immunization upon admission, with documentation of any efforts to obtain immunization information. During interview, the Unit Manager stated she reviews immunization records for new and current residents, handles consents, and that staff administer the vaccines; she also stated education is provided verbally if a resident or activated POA declines and documented in the EMR. However, when the surveyor raised concern that R12’s EMR lacked documentation of an influenza vaccine offer, receipt, or refusal, the Unit Manager stated R12 declined to provide a SSN to look up records in the Wisconsin Immunization Record and said R12 refused immunizations. The handwritten documentation provided by the Unit Manager referenced COVID-19 consent and conversations about declining immunization, but it did not document influenza vaccination, and the Unit Manager stated no further vaccine offers had been made beyond what was documented.
Missing COVID-19 Immunization Documentation in Resident EMRs
Penalty
Summary
The facility did not ensure medical records contained documentation related to COVID-19 immunizations for 3 of 5 residents reviewed for immunizations. R9, R11, and R12 each had EMRs that did not show whether they were offered, received, or declined the COVID-19 vaccine. R9 was admitted with diagnoses including tracheostomy, encephalopathy, laryngeal hypoplasia, aneurysm of an artery, and type 2 diabetes, and the surveyor found no EMR documentation for COVID-19 immunizations in 2023, 2024, or 2025, although R9 had received a Moderna booster on 5/3/22. R11 was admitted with diagnoses including autistic disorder, epilepsy, dementia, dysphagia, and gastrostomy, and the EMR also lacked documentation showing whether the vaccine was offered, received, or declined. R12 was admitted with chronic respiratory failure, congestive heart failure, and chronic kidney disease, and the EMR likewise lacked documentation of vaccine offer, receipt, or refusal. During interview, the UM stated she reviews immunization records for new and current residents, offers COVID-19 immunizations, and documents education and refusals in the EMR immunization tab. When the surveyor identified the missing documentation, the UM stated R12 had declined to provide an SSN to look up immunization records in the Wisconsin Immunization Record and said R12 refused the COVID-19 immunization, while R9 had not been offered because R9 goes in and out of the hospital. The UM later provided handwritten immunization-related notes, including voicemail attempts for R9 and R11 and a baseline testing consent form for R12 noting refusal to provide SSN and prior vaccine conversations, but these records were not in the EMRs. The DON acknowledged the concern that the EMRs did not contain documentation that the COVID-19 vaccine was offered, received, or declined.
Failure to Reposition Resident Promptly
Penalty
Summary
The facility did not ensure that a resident who was unable to perform activities of daily living received the necessary assistance with repositioning and boosting in bed. The resident had diagnoses including chronic kidney disease stage 3, COPD, morbid obesity, asthma, dysphagia, anxiety disorder, major depressive disorder, hypertension, gout, GERD, and hereditary and idiopathic neuropathy. Her BIMS score was 15, indicating no cognitive impairment. Her admission MDS documented impairment in both lower extremities and partial/moderate assistance needed for rolling left and right, and PT discharge documentation listed bed mobility roll left and right as substantial/maximal assistance. During observation, the resident was lying on her back in bed and told the surveyor she wanted to be boosted up because staff said they could not help her due to not wanting to hurt their backs. After the surveyor requested assistance, a CNA entered but stated she could not do it by herself and left to get help. The resident remained in the same position for an extended period, became tearful, and stated her back hurt and she could not eat because of the pain. The surveyor later asked an LPN for help, and the resident was eventually repositioned more upright with pillows. The resident then stated she felt better but said she was no longer hungry and did not eat lunch, despite CNA point-of-care documentation indicating she consumed 75% of the meal.
Missing physician order for resident code status
Penalty
Summary
The facility did not ensure its procedures for documenting resident code status were followed for one resident. The facility policy on Communication of Code Status states that when an order is written regarding a resident’s presence or absence of an advance directive, the directions must be clearly documented in designated sections of the medical record, including physician orders obtained per election form and the signed election form uploaded. R11 was admitted to the facility and has a legal guardian. On 7/7/25, R11’s guardian signed for R11 to be full code status, but survey review found no current physician order for full code status in R11’s chart. Surveyors reviewed R11’s record and confirmed that the current physician orders did not document full code status. An LPN stated that staff have basic unit information including code status and would also check the EMR, but when the EMR was reviewed, R11 did not have a current code status listed. A SWA stated that she did not obtain or maintain code status in the EMR and would only verify code status during care conferences; surveyors noted that R11 had not had a care conference. The NHA stated the expectation was that each resident should have a physician order for code status.
Pharmacist Medication Regimen Review Irregularities Not Sent and Acted Upon
Penalty
Summary
The facility did not ensure that irregularities identified by the consultant pharmacist during Medication Regimen Review were sent to the attending physician and acted upon for 2 of 5 residents reviewed for unnecessary medications. The facility policy titled “Addressing Medication Regimen Review Irregularities (Pharmacist Recommendations)” stated that the pharmacist must report irregularities to the attending physician, medical director, and DON, and that the attending physician must document review and any action taken in the resident’s record. For one resident with chronic kidney disease stage 3, COPD, morbid obesity, asthma, dysphagia, anxiety disorder, major depressive disorder, hypertension, gout, GERD, and hereditary and idiopathic neuropathy, the MAR showed alprazolam 0.25 mg every 8 hours as needed for anxiety starting 8/12/25. The pharmacist’s 8/22/25 review noted the resident had used alprazolam 10 times since it started and documented that PRN psychotropic orders require no more than 14 days unless clinical rationale and a specific duration are provided. The recommendation was to discontinue alprazolam or provide rationale for continued PRN use, but the form was not checked. The physician response was dated 9/23/25 and stated the resident continued to take alprazolam PRN daily and the medication should be scheduled daily. The DON stated the pharmacy sends her an email and she notifies the NP or doctor. For another resident with autistic disorder, repeated falls, unspecified intellectual disabilities, epilepsy, mood disorder, anxiety disorder, and gastrostomy, the admission MDS documented severely impaired cognitive skills, memory deficits, moderate depressive symptoms, behaviors interfering with care, rejection of care, and wandering. The pharmacist’s July 2025 review identified PRN lorazepam and temazepam since admission and recommended discontinuing or providing rationale for continued PRN use, but neither option was checked. A second July 2025 review identified duplicate olanzapine and high-dose quetiapine, along with multiple other psychotropic medications, and recommended a gradual dose reduction or continuation rationale; neither option was checked. A September 2025 review identified possible transcription error with valproate dosing, scheduled lorazepam 1 mg every 4 hours, olanzapine 30 mg at bedtime, and temazepam 30 mg at bedtime, and again neither recommendation/option was checked. A handwritten note stated the review was discussed with the MD by phone, and the NHA documented medication changes and clarifications after the pharmacist reports.
Delayed Therapy Evaluation and Treatment
Penalty
Summary
The facility did not ensure specialized rehabilitative services were provided in a timely manner for two residents who had physician orders for therapy evaluation and treatment. For one resident, R11, a physician order for PT, OT, ST, and RT evaluation and treatment was initiated on 9/11/25, but the therapy evaluation was not completed until 9/22/25. The record also showed that a speech therapy screen was completed on 9/11/25 and documented no treatment was indicated at that time, while the later unsigned therapy screen on 9/22/25 stated the resident would not benefit from skilled therapy services because the resident was at baseline and had aggressive behaviors limiting participation. R11 was admitted with diagnoses including autistic disorder, repeated falls, unspecified intellectual disabilities, epilepsy, mood disorder, anxiety disorder, and gastrostomy. The admission MDS documented severely impaired cognitive skills, short- and long-term memory deficits, moderate depressive symptoms, daily rejection of care and wandering, and need for assistance with several ADLs. Therapy Director-VV stated that a screen and/or evaluation should be completed within three days of a physician order, but the OT and PT screens were completed 11 days after the order. Surveyor notes also stated that the therapy disciplines relied on prior documentation and did not physically re-assess the resident after readmission. For the second resident, R50, the physician documented on 6/20/25 that PT and OT evaluation and treatment were needed, and the admission H&P also stated PT and OT were to evaluate and treat. R50 had diagnoses including chronic respiratory failure with tracheostomy, quadriplegia, epilepsy, gastrostomy, stroke with hemiplegia, and metabolic encephalopathy. The admission MDS documented severe cognitive impairment and dependence for all cares, toileting, and mobility. Although the resident had an order for PT/OT/ST/RT evaluation and treatment and a screening tool dated 6/17/25 noted no evaluation, PT and OT services did not begin until 7/11/25, more than three weeks after admission. The Medical Director stated the resident absolutely should have started closer to admission and would have benefited from therapies at least weekly after admission.
Failure to Ensure Nursing Staff Competency in Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skills to safely administer medications, as evidenced by an incident involving a newly graduated LPN who administered 15 units of lispro insulin to a resident with type II diabetes mellitus, instead of the prescribed 4 units. The resident's blood sugar was checked at 185, and the error was discovered after the medication was given. The resident did not experience any adverse effects during the monitoring period following the incident. Interviews revealed that the LPN was still in orientation and was supposed to be supervised by another nurse, but due to a staff call-off, she was assigned her own cart and responsibilities without documented evidence of completed orientation or skills check-off. Both the administrator and the orienting nurse confirmed that the facility did not have a formal process for documenting orientation or competency check-offs prior to allowing new nurses to work independently. Facility policies and assessments indicated that such check-offs were required, but these were not followed in practice.
Significant Medication Error: Incorrect Insulin Dose Administered
Penalty
Summary
A significant medication error occurred when a resident with type II diabetes mellitus, who was assessed as severely cognitively impaired, was administered an incorrect dose of insulin. The physician's orders specified that the resident should receive 15 units of insulin glargine at bedtime and a sliding scale dose of insulin lispro before meals and at bedtime, with 4 units indicated for a blood sugar reading of 185. However, the resident was mistakenly given 15 units of insulin lispro instead of the prescribed 4 units. The error was identified shortly after administration when the LPN realized the mistake upon returning to the medication cart. The incident was reported immediately to the night supervisor, and the responsible party and medical provider were contacted. The resident was monitored for adverse effects, but no negative outcomes were observed during the monitoring period. The deficiency was attributed to the failure to follow the physician's orders during insulin administration.
Failure to Adhere to Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During wound care for a resident on Enhanced Barrier Precautions (EBP), two Licensed Practical Nurses (LPNs) failed to wear gowns as required by the facility's infection control policy. The policy specifies that gowns and gloves must be used during high-contact care activities, such as wound care, for residents with wounds or medical devices like feeding tubes, urinary catheters, or tracheostomy tubes. Despite an EBP sign posted on the resident's door and the resident's care plan indicating the need for EBP due to impaired immunity and multiple invasive devices, the LPNs only performed hand hygiene and donned gloves, omitting the use of gowns. The resident involved had chronic respiratory failure, peripheral vascular disease, severe cognitive impairment, and was dependent on multiple medical devices, including an indwelling urinary catheter, feeding tube, and tracheostomy. The LPNs acknowledged after the incident that they should have worn gowns, attributing the oversight to the location of the gowns being on the other side of the hall. The Director of Nursing confirmed that EBP protocols require gown and glove use for hands-on care involving wounds or invasive devices.
Insufficient Clean Linen Supply for Resident Care
Penalty
Summary
The facility failed to ensure a sufficient supply of clean linen was readily available for resident care in three of four linen closets observed across both floors. Multiple alert and oriented residents, including members of the Resident Council, reported that the facility was often low on linens such as towels and washcloths, resulting in delays for showers and personal care. Some residents resorted to stockpiling linens in their rooms to avoid running out. Observations confirmed that linen carts in several units contained only a small number of towels and washcloths, insufficient for the needs of the residents. Interviews with CNAs and an LPN corroborated the shortage, stating that they sometimes had to wait for laundry to deliver more linens, causing delays in resident care, particularly in the mornings and on weekends. The Laundry Manager was unaware of any ongoing issues and stated that linen was distributed twice daily based on census calculations. The DON confirmed there was no policy for maintaining sufficient laundry for resident use, and the Administrator noted that linens are counted daily and more can be ordered if needed, but acknowledged losses due to linens being thrown away or lost.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for a resident, identified as R1, who was at moderate risk for falls due to a history of traumatic brain injury and significant cognitive impairment. R1 was totally dependent on staff for all activities of daily living and required assistance from at least two staff members for bed mobility. Despite these needs, a certified nursing assistant (CNA1) provided care to R1 without the assistance of another staff member, contrary to the resident's care plan. During the provision of routine care, R1 fell from his bed, resulting in significant injuries, including a broken hip and a large laceration on his forehead that required nine staples. The facility's policy on accidents and supervision mandates that the resident environment should be as free of accident hazards as possible and that adequate supervision should be provided based on the resident's assessed needs. However, the failure to adhere to the care plan and provide the necessary supervision led to the accident. The facility's investigation confirmed that CNA1 did not follow R1's established plan of care, which required two staff members for bed mobility. This oversight directly contributed to the resident's fall and subsequent injuries. The incident highlights a lapse in following the care plan, which was acknowledged by the facility's administration during an interview with the surveyor.
Delayed Reporting of Alleged Care Violation
Penalty
Summary
The facility failed to report an alleged violation concerning a resident's care to the State Agency within the required timeframe. A family member of a resident expressed concerns about the resident's incontinence care on a specific date. The facility was required to submit a report of the investigation to the State Agency within five working days of the initial allegation. However, the report was submitted late, on a date beyond the required timeframe. The Nursing Home Administrator acknowledged the delay and attributed it to technical issues with the submission process. The resident involved is an elderly individual with multiple diagnoses, including dysphagia, dementia, stroke, and muscle contracture. The resident is dependent on staff for various activities of daily living and is always incontinent of bowel and bladder. The care plan for the resident includes specific interventions for incontinence care, which were discussed with the resident's family. Despite the facility's documentation of care provided on the day in question, the family alleged that no care was given throughout the day. The facility's investigation found no concerns from staff or resident statements, and a skin check revealed no issues.
Failure to Assign Charge Nurse on Each Shift
Penalty
Summary
The facility failed to ensure a charge nurse was assigned for each shift, potentially affecting all 95 residents. During a review of staffing schedules from January to March 2024 and July 2024, it was found that the schedules did not indicate which nurse was assigned as the charge nurse for each shift, nor did they specify whether each nurse was a Registered Nurse or Licensed Practical Nurse. Scheduler-E, when interviewed, admitted to not knowing the requirement to indicate the charge nurse on the schedule, relying instead on personal knowledge of who it was for each shift. Director of Nurses (DON)-B also confirmed that each of the four wings had its own charge nurse, but this was not documented on the schedule. On a subsequent review of the schedule for 7/30/24, it was noted that the nurses' titles and the designation of a charge nurse per shift were included. The findings were discussed with the Nursing Home Administrator and DON, but no additional information was provided to explain the lack of identification of a charge nurse on the schedule.
Failure to Follow Standardized Recipes for Pureed Diets
Penalty
Summary
The facility failed to ensure that food was prepared to conserve nutritive value and flavor for residents on a pureed diet. During an observation, Cook-C was seen preparing pureed Salisbury steak without following the standardized recipe. Cook-C added an unmeasured amount of water and instant potatoes to the pureed Salisbury steak, indicating it was too thin. Additionally, Cook-C pureed carrots without a recipe, using an unmeasured amount of liquid from a can. This preparation method was not in accordance with the facility's policy, which requires following standardized recipes for pureed diets. The Food Service Director (FSD)-D confirmed that Cook-C should have been following the recipes for pureed food. However, a recipe for pureed carrots was not available in the recipe book at the time of preparation, and Cook-C did not measure the ingredients. The facility's policy on Pureed Diet Preparation and Portion Control mandates the use of standardized recipes, which was not adhered to in this instance. The deficiency was discussed with the Nursing Home Administrator and Director of Nurses, but no additional information was provided to explain why the recipes were not followed.
Failure to Timely Complete Significant Change MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change in status assessment MDS for a resident who elected to receive hospice services. The resident, who was admitted with Alzheimer's Disease, Dementia, cognitive communication deficit, and unspecified psychosis, was rarely or never understood according to their annual MDS. On the date the resident began hospice services, the facility did not complete the required Significant Change MDS. A surveyor noted that the MDS was in progress but not completed or submitted over a month later. The MDS Coordinator acknowledged that significant changes are discussed in morning reports and stated that the MDS should be completed within 14 days of the change. However, the MDS for this resident was not completed in a timely manner, with different sections being completed on various dates, and the surveyor highlighted this concern to the Director of Nursing.
Failure to Provide Timely Audiology Services
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain their hearing abilities. The resident, who was admitted with a primary diagnosis of dementia, was noted to have adequate hearing and did not use hearing aids according to their admission Minimum Data Set (MDS). However, during an interview, the surveyor observed that the resident had significant hearing difficulties and did not have hearing aids. An order for an audiology consult regarding hearing aids was placed on 01/17/2024, but there was no documentation of its completion. Another order dated 03/11/2024 indicated the need for an audiology setup due to hearing difficulty, yet the appointment remained pending as of 07/23/2024. Despite a progress note acknowledging the resident's hearing issues, the audiology consult was not arranged until a fax was sent on 07/31/2024, following the surveyor's request for documentation.
Failure to Provide Prescribed Splinting for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and equipment to prevent further decline. The resident, diagnosed with Huntington's disease, muscle wasting and atrophy, and muscle weakness, was observed multiple times without the prescribed hand splint, which was intended to be worn for 12 hours, twice a day. The care plan specified the use of hand splints for four hours at a time, but observations on several occasions revealed the resident's hand was not splinted and was clenched into a fist, indicating a lack of adherence to the care plan. Interviews with staff revealed confusion and miscommunication regarding the whereabouts and application of the hand splint. A CNA mentioned the splint was in the resident's drawer, while an LPN stated it had been sent to laundry due to a spill, yet the laundry manager could not locate it. The rehabilitation manager later confirmed the splint was in the resident's room. Despite these findings, no additional information was provided to explain why the resident did not receive the necessary treatment and equipment to maintain or improve range of motion.
Improper Catheter Care Leading to Deficiency
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate care to prevent urinary tract infections. The facility's policy on catheter care, revised on 10/16/2023, outlines specific steps for cleaning the genital area and catheter tubing. However, during an observation on 08/01/2024, a surveyor noted that a CNA did not follow these procedures correctly. The CNA used a washcloth to clean the resident's genitals, starting at the urethral meatus and moving down to the base of the penis. After obtaining a new washcloth, the CNA began cleaning from the base of the penis and in between the thighs, then used the same washcloth to clean the urethral meatus and catheter tubing, which is inconsistent with the facility's policy. The resident involved, who has a diagnosis of neuromuscular dysfunction of the bladder, acute cystitis, and dementia, was admitted to the facility with an indwelling catheter. The resident had a history of hospitalization for urosepsis and a recent positive urine culture requiring intravenous antibiotics. The surveyor intervened during the observation and later informed the Nursing Home Administrator and Director of Nursing about the improper catheter care provided to the resident.
Deficiencies in Enteral Feeding and Hydration Management
Penalty
Summary
The facility failed to ensure that residents receiving enteral feeding were provided with appropriate services to prevent complications. For one resident, there was a discrepancy between the enteral feeding orders and what was documented in the medical record, leading to a significant weight loss. The resident had orders for enteral feeding seven times a day, but the medical record showed it was administered five times a day. This discrepancy resulted in a reduction of water flushes, which are crucial for hydration, and there was no documentation or communication with the Registered Dietitian (RD) regarding the specific formula and water flushes provided. The RD's documentation did not accurately reflect the resident's actual feeding regimen, and the resident experienced a significant weight loss over two months without timely notification to the physician or dietitian. Another resident also experienced issues with enteral feeding orders not correlating with the RD's documentation. The resident's orders for water flushes did not match the feeding schedule, leading to potential dehydration. Observations revealed the resident had dry lips and a buildup around the mouth, indicating possible dehydration. The RD acknowledged the discrepancy in the orders and planned to update the medical record after physician approval. However, the resident continued to show signs of dehydration, and the facility's statement attributed the dryness to mouth breathing rather than addressing the incorrect fluid administration. Both cases highlight a lack of communication and coordination between nursing staff and the dietitian, resulting in residents not receiving the correct amount of nutrition and hydration. The facility's policies on feeding tubes and hydration were not followed, leading to discrepancies in feeding schedules and water flushes. The failure to accurately document and communicate the residents' feeding regimens and hydration needs contributed to the deficiencies observed by the surveyors.
Improperly Fitted Bed Linens for Resident
Penalty
Summary
The facility failed to ensure that a resident had bed linens in good condition that properly fit the bed, as observed by surveyors. During two separate observations, the resident was found lying on a bed with a fitted sheet that did not cover the entire mattress. On one occasion, the resident's head was directly on the mattress with the pillow off to the side, and on another occasion, the resident's lower body was directly on the mattress. The fitted sheet was not adequately covering the bolstered air mattress, indicating a deficiency in providing a safe and comfortable environment for the resident. Interviews with facility staff revealed that there were bariatric fitted sheets available, which should have fit the resident's mattress. However, the staff did not consistently keep the fitted sheets organized, leading to a mix-up between regular and bariatric sheets. The Laundry Manager confirmed that the bariatric sheets were marked with red stitching for identification, but the staff's failure to use the correct sheets resulted in the observed deficiency. The Nursing Home Administrator and Director of Nursing were informed of the issue, but no further information was provided at that time.
Deficiency in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with pressure injuries. The resident, who had a history of traumatic brain injury, quadriplegia, and other significant medical conditions, developed two blisters on their left hand after staff removed a hand splint. The comprehensive care plan for the resident did not include interventions for the use of hand splints, and the treatment administration record (TAR) was not updated to document when the hand splint or palm guard should be applied. The facility's policy on pressure injury prevention and management emphasizes the importance of a systemic approach, including prompt assessment, treatment, and modification of interventions as needed. However, the resident's care plan and TAR were not revised after the blisters developed, and there was no order for the palm guard to be used when the splints were not in place. Staff continued to sign the TAR, indicating that the hand splints were being applied every four hours, despite the resident's left hand splint needing to be on hold until the blisters healed. Interviews with the wound doctor, wound nurse, and rehab manager revealed that the blisters were likely caused by the hand splints, and it was recommended that the left hand splint be held until the wounds healed. Despite these recommendations, the care plan and TAR were not promptly updated to reflect the necessary changes, leading to continued confusion among staff about the resident's current treatment plan. The lack of documentation and communication regarding the resident's care plan and TAR contributed to the deficiency identified by the surveyor.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, identified as R37, during meal times to prevent choking. R37 has a diagnosis of schizophrenia and requires a pureed diet with close supervision due to dysphagia, as recommended by a speech therapist. The resident's care plan specifies the need for constant supervision while eating, to be seated upright, and to take small bites with liquid washes every 4-5 bites. Despite these requirements, R37 was observed eating breakfast alone in their room without staff supervision. Interviews with facility staff revealed a lack of consistent adherence to the supervision requirements for R37. A CNA mentioned that R37 typically eats breakfast in their room and is checked on periodically, indicating a misunderstanding of the need for constant supervision. The Director of Nurses acknowledged that R37 is usually supervised during meals, even in their room, but this was not the case during the surveyor's observation. The Unit Manager, new to the role, was unaware of R37's specific meal supervision needs and stated they would investigate further. This lack of supervision was communicated to the Nursing Home Administrator and Director of Nurses during the facility exit meeting.
Inaccurate PASRR Documentation in MDS Assessments
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the residents' status concerning the Preadmission Screening and Resident Review (PASRR) for five residents. These residents, who had diagnoses of mental disorders such as schizophrenia, depression, bipolar disorder, anxiety, and unspecified psychosis, had completed PASRR Level I and Level II evaluations. However, this information was not correctly entered into the Minimum Data Set (MDS) comprehensive assessment, specifically in Section A1500, which asks if the resident has been evaluated by Level II PASRR and determined to have a serious mental illness or related condition. The MDS assessments for these residents incorrectly documented 'no' to this question, despite their diagnoses and completed PASRR evaluations. The issue was identified during a surveyor's interview with the MDS Coordinator (MDS-O), who stated that Social Services should handle Section A of the MDS due to their knowledge of PASRRs. MDS-O mentioned that the residents' Level I and Level II PASRRs might not have been scanned into their records, which is why they were not seen. However, the surveyor confirmed that all PASRRs were visible. The deficiency was further discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the incorrect coding of the MDS assessments and the need for accurate documentation of PASRR evaluations.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries and promote healing for three residents. One resident, who was admitted with no pressure areas, was identified as being at moderate risk for pressure injury development. However, the facility did not develop a skin integrity care plan until the resident developed an unstageable pressure injury on the sacrum. The care plan interventions were not person-centered, and there was a lack of monitoring of the resident's food, fluid intake, and repositioning. Additionally, upon the resident's return from hospitalization, the sacrum pressure injury was not comprehensively assessed until a week later. Another resident's pressure injury on the left buttock was not comprehensively assessed until five days after admission, and the care plan did not include individualized interventions to prevent the decline of the pressure injury. A third resident's air mattress was not set according to their weight, leading to the decline of a pressure injury from Stage 2 to Stage 3, which was identified as actual harm. The facility's policy on pressure injury prevention and management was not followed, as evidenced by the lack of prompt assessment and treatment, failure to monitor the impact of interventions, and failure to modify interventions as appropriate. The facility's failure to develop and update care plans, monitor residents' conditions, and provide individualized care contributed to the development and worsening of pressure injuries, resulting in a finding of Immediate Jeopardy.
Inadequate Catheter and Bowel Care Leads to Infections
Penalty
Summary
The facility failed to provide appropriate catheter care and bowel management for a resident, leading to urinary tract infections and bowel incontinence. The resident, who was admitted with a Foley catheter for wound protection, did not have a comprehensive care plan or physician orders for catheter care and monitoring. Despite being assessed as continent of bowel and bladder upon admission, the resident became incontinent of bowel, and there was no toileting program or monitoring in place to address this change in condition. The facility's policies on indwelling catheter use and incontinence were not followed, as there were no documented assessments or care plans for the resident's catheter use. The resident developed two urinary tract infections, and there was a lack of documentation regarding catheter care, including the size of the catheter, catheter changes, and monitoring of the catheter insertion site. Additionally, the resident's bowel habits were inconsistently documented, and there was no care plan to address bowel continence or incontinence. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's bowel and catheter care. Certified Nursing Assistants (CNAs) did not consistently report the resident's bowel movements or catheter care, and the Director of Nursing (DON) was unaware of the resident's bowel habits. The facility did not have a bowel monitoring policy, and the resident's care plan did not include specific interventions for bowel or catheter care, contributing to the resident's decline in continence and the development of urinary tract infections.
Failure to Address Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure that grievances and recommendations discussed during Resident Council meetings were acted upon promptly and did not demonstrate their response and rationale for such requests. The grievance log generated from these meetings lacked essential details, including the name of the resident filing the grievance, grievance specifics, how the grievances were investigated, and the outcome of each investigation. This deficiency has the potential to affect all 98 residents residing at the facility. During the Resident Council meetings, several issues were raised by the residents, including administrative, nursing, maintenance, dietary, housekeeping, and activity department concerns. Residents reported delays in receiving food trays, staff using earbuds and personal phones during care, and issues with personal laundry and housekeeping practices. Additionally, residents expressed dissatisfaction with the timeliness of responses to their grievances and the lack of follow-up on previously raised concerns. Interviews with residents and staff revealed that the facility's grievance process was not effectively managed. Residents reported that grievances were not consistently addressed or resolved, and there was a lack of communication regarding the status of their complaints. The facility's grievance officer and other management staff were aware of the grievances but failed to ensure timely and appropriate responses, leading to ongoing dissatisfaction among residents.
Failure to Provide Notice of Resident Rights and Services
Penalty
Summary
The facility failed to provide notice of resident rights and services prior to or upon admission for all 40 residents reviewed. This deficiency was identified through interviews and record reviews conducted by the surveyor. The facility's policy requires that all residents have a signed and dated admission agreement on file, which includes a notice of rights and services. However, the surveyor found that none of the residents had a signed admission agreement at the time of admission. The surveyor's investigation revealed that the facility had transitioned from paper admission agreements to a digital CareFeed program, and it was unclear if the agreements were properly transferred. The Resident Care Coordinator (RCC) responsible for obtaining signatures admitted to the surveyor that there were issues with getting the agreements signed, especially for residents admitted after hours or on weekends. The RCC also mentioned that they had been trying to obtain signatures from residents and their families, but had not received responses. Specific cases highlighted in the report include a resident who was admitted with diagnoses such as hemiplegia, type 2 diabetes mellitus, and major depressive disorder, who did not have a signed admission agreement on file. Another resident's Power of Attorney for Healthcare was not provided with the admission agreement until the day before discharge, and the POA refused to sign it. The Nursing Home Administrator acknowledged the issue and stated that the facility was aware of the problem and working to correct it.
Failure to Timely Report Incidents
Penalty
Summary
The facility failed to report three out of four incidents to the State survey agency and/or Nursing Home Administrator within the required timeframe, potentially affecting several residents. One incident involved a resident with dementia, congestive heart failure, atrial fibrillation, anxiety, hypertension, and bipolar disorder, who was accused of inappropriate behavior towards another resident. The incident was not reported to the Nursing Home Administrator and State agency immediately, as required by the facility's policy, which mandates reporting within two hours if the allegation involves abuse. Another incident involved a possible drug diversion, where discrepancies with controlled substance medications were noted for several residents. The issue was not reported to the Nursing Home Administrator and State agency within 24 hours, as required. The delay in reporting was attributed to a staff member wanting more information before escalating the concern, which was against the facility's policy of reporting any concerns immediately. Additionally, a resident with a fully intact cognitive status accused staff of misappropriation and assault after an incident involving self-inflicted injury. The allegation was not reported to the State agency within the required 24-hour timeframe. The delay was due to the Nursing Home Administrator not being informed of the incident until two days later, resulting in a late report to the State agency.
Inadequate Safeguarding of Medical Records
Penalty
Summary
The facility failed to ensure that confidential medical records were safeguarded against loss, destruction, or unauthorized use, potentially affecting up to 30 current residents. During a surveyor's tour of the medical records archive room, it was observed that ten cardboard boxes containing approximately 30 current and previous resident medical records were stored on the floor in the basement. These boxes were positioned directly below a water fire sprinkler, and the boxes were open without lids, leaving the records vulnerable to water damage. When questioned by the surveyor, Medical Records-OO acknowledged that if the fire sprinkler were activated, the records would be ruined. Medical Records-OO also confirmed that the medical records should be stored off the floor and secured in a covered metal cabinet to prevent such damage. During the exit meeting, the surveyor informed the Nursing Home Administrator and the Director of Nursing about these findings, but no additional information was provided to explain why the facility did not ensure the safeguarding of these confidential medical records.
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 468 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kenosha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avina Of Kenosha | 1.3 mi | ★★★★★ | 2 | 0 |
| Brookside Care Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Clairidge House | 1.8 mi | ★★★★★ | 28 | 0 |
| Sheridan Health And Rehabilitation Center | 3.8 mi | ★★★★★ | 22 | 0 |
| Avina On 32nd | 4.2 mi | ★★★★★ | 3 | 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.