Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Williams Bay Health Services during CMS and state inspections, most recent first.
A resident who was dependent for all ADLs and at risk for pressure injuries developed a right buttock wound that progressed from an abrasion to a stage 4 PI with infection, requiring hospitalization, surgical debridement, antibiotics, and a wound VAC. Surveyors observed concerns during wound care and incontinence care, including infection control issues and lack of offloading after care, and staff gave conflicting accounts about whether the resident was noncompliant with repositioning.
A facility failed to prevent accident hazards and provide adequate supervision for multiple residents. One resident with COPD, legal blindness, and hospice care had increasing weakness, restlessness, and altered mental status before an unwitnessed fall that resulted in a hip fracture. Another resident with CVA, aphasia, and severe cognitive impairment had an unwitnessed fall with a facial fracture, while a resident with Alzheimer’s disease and dysphagia was observed drinking through a straw despite a no-straw order and care plan. A fourth resident with depression, anxiety, and repeated unwitnessed falls had incomplete fall investigations, sustained toe fractures, and made a suicidal statement without documented safety interventions at the time.
Food Stored on Freezer Floor: A surveyor observed three opened cardboard boxes containing cookie dough, turkey breast, and orange juice resting directly on the floor of the walk-in freezer in the main kitchen. The DM stated the facility follows Wisconsin Food Code, but was unsure why the boxes were on the floor; one box of orange juice was meant to be returned to the supplier because it was the wrong type, and the other two boxes had no explanation provided.
QAPI Program Not Implemented as Written: The facility did not implement its QAPI process for feedback, data collection, monitoring, or adverse event monitoring for 33 of 33 residents, and it did not maintain written PI documentation, PIPs, or monitoring of effectiveness as described in its policy. The NHA stated dept heads met monthly, the Medical Director attended quarterly, and there were no formal PIPs in writing, while surveyors identified pressure injuries, significant med errors, and other harm-level concerns that QAPI had not identified.
Behavioral health training was not found for 8 of 8 staff reviewed, including an LPN, a housekeeper, a cook, and multiple CNAs. Records showed they had completed other required training, but surveyors could not locate behavioral health training for any of them. Facility leaders said training was assigned through the training system and monthly in-services, and the NHA stated the facility did not have a training policy.
The facility failed to follow its abuse prevention policy by not completing required criminal background checks before hiring 4 of 8 employees reviewed. Records showed that an RN, a life enrichment staff member, and 2 CNAs had DOJ/IBIS and related background checks completed after hire, and one staff member also had an out-of-state check completed late. The NHA stated background checks had not been done for new hires before the NHA began working at the facility and agreed this was a problem.
Insulin Pen Administration Competency Deficiency: An RN did not demonstrate the required competency to administer insulin from a pen to a resident with diabetes. The RN failed to clean the rubber seal before attaching the needle, did not know how to prime the pen until instructed by the surveyor, and did not hold the injection button down for the required 10 seconds during administration. The RN also could not recall any specific training on insulin pen use.
Staff failed to maintain infection control during multiple resident care activities. An RN touched oral meds with bare hands during med pass, two RNs performed wound care and incontinence care without proper hand hygiene or clean-to-dirty separation, and CNAs provided care to a resident on EBP without the required PPE or hand hygiene. An uncovered rack of unclaimed clothing was also left in the dining room.
A facility failed to ensure pneumococcal immunizations were offered and documented for 4 of 5 sampled residents reviewed. Four residents were not current with their pneumococcal vaccines, and the record review found no evidence that the vaccine was administered, offered, or declined. The DON and RN infection preventionist stated immunization information should be in the medical record, and the DON noted one resident reportedly declined at a care conference, but there was no documentation of the discussion.
A resident admitted for therapy after an influenza hospitalization reported mild left knee pain with observed swelling to PT, but the physician was not notified until later. Record review also showed an earlier wheelchair-related leg injury with pain and monitoring instructions, yet there was no documented provider notification or follow-up monitoring in the EHR.
A resident receiving wound treatment to the right buttock did not have privacy maintained because the window blinds remained open during the procedure and incontinence care. RN-O and RN-P did not ask the resident if the blinds should be closed, and the window faced outside where people could possibly observe the care. The resident was cognitively intact and dependent for all ADLs, transfers, and bed mobility, with bladder and bowel incontinence.
Unrepaired Room Damage in Residents' Rooms: Two residents had visible room damage that remained unaddressed for over a year. One resident with COPD, DM2, anxiety, and schizophrenia had a large hole in the room wall, and another resident with CKD, DM2, PTSD, bipolar disorder, and schizophrenia had a large area of missing paint. Both residents said the conditions bothered them, and the MD acknowledged knowing about the issues for an extended period.
Failure to Report Suspected Injury of Unknown Source: A resident with Alzheimer's disease and severe cognitive impairment developed a bruise and bump on the forehead, and the resident could not explain what happened. The facility investigated possible causes, including combative behavior during care and possible contact with a mechanical lift bar, but did not report the event to the state agency because leadership believed the injury was easily explained by CNA observations.
Bed-Hold Notices and Ombudsman Notifications Not Consistently Provided: The facility did not provide written bed hold notices to residents’ representatives when residents were transferred to the hospital, and it did not consistently notify the State LTC Ombudsman of resident transfers/discharges. A resident with impaired cognition and two residents with intact cognition were hospitalized for conditions including anemia, thrombocytopenia, COVID, urinary stones, and severe head/neck pain; records showed phone confirmation for bed holds, but written notice to representatives was not provided in some cases and Ombudsman notification was missed for multiple monthly reporting periods.
Care Plan Did Not Include Assessed Bed Rail Use: A resident with cerebral palsy and quadriplegia was assessed as using bed rails daily and stated she used them during cares, but the care plan did not include siderail use. Surveyors also observed RNs repositioning the resident without use of the bed rail, and the DON stated siderails should be included in the care plan when assessed for use.
Delayed Response to Resident Call Light for Toileting Assistance. A resident with right femur fractures, intact cognition, and an ADL care plan requiring 1-person assist for toileting had a call light go unanswered for 35 minutes while needing toileting help. Staff walked past the room without responding, and the resident stated staff did not answer in time and the resident had to go in the brief.
Failure to assess and monitor left lower extremity injury: A resident with MS, dementia, and weakness had a leg injury after the leg became stuck under a wheelchair, followed by ongoing swelling, pain, and decreased function. Nursing and therapy notes documented repeated L knee/LLE swelling over several weeks, but there was no documented thorough assessment or consistent monitoring, and provider notification was delayed until the resident had progressive edema, pain, and immobility. A doppler was ordered to rule out DVT, and an x-ray later confirmed a tibial plateau fracture.
A resident admitted with a urostomy, indwelling catheter, MS, UTI, and dementia did not receive appropriate urostomy care because the facility did not have the proper supplies available. Records showed the resident still needed urostomy supplies after admission, and staff interviews revealed confusion about ordering and access to supplies, with the facility sometimes relying on the resident’s wife to bring in needed wafers and pouches.
A facility failed to comprehensively assess 3 residents for trauma and did not develop individualized trauma-informed care plans with specific triggers and interventions. One resident had documented military deployment, severe depression/anxiety, prior psychiatric hospitalizations, family suicide history, and past suicidal ideation; another had an incomplete trauma-informed care assessment with 8 unanswered questions and a non-individualized care plan; and a third had PTSD, bipolar disorder, schizophrenia, and documented trauma related to witnessing a suicide, yet the assessment and care plan remained generic. Staff were not aware of the residents’ trauma histories or triggers, and the SSC stated psychology notes were far behind in review.
Failure to Provide Behavioral Health Services: The facility did not ensure needed behavioral health care for 3 residents with mood concerns. One resident with PTSD and depression requested in-person psychotherapy, but the facility only offered zoom and made no attempt to provide in-person therapy. Another resident with anxiety and depression expressed suicidal ideation, but no suicidal evaluation was documented, the physician was not notified, and no focused care plan addressed the statement. A third resident with PTSD, bipolar disorder, and schizophrenia also requested in-person psychotherapy, but the facility did not facilitate it.
A resident with PTSD, MDD, paraplegia, and ESRD needed a wider wheelchair after therapy determined the current chair was too small, but the chair was not replaced because it would not fit on the current transport van for dialysis. The resident continued using a broken wheelchair with busted sides, while staff discussed alternate placement instead of resolving the transport and equipment issue. Social services documentation was lacking, and the resident was tearful and distressed about being forced to leave a place that had been home for years.
A resident with hypertensive heart and CKD, anxiety, and chronic diastolic CHF had a pharmacy MRR that recommended changing scheduled Benzonatate 100 mg daily to PRN. The practitioner approved the change, but the facility did not update the order, and the resident continued receiving scheduled Benzonatate until it was later discontinued. The NHA stated the usual follow-up process was lost during a period with interim DONs.
A resident with HTN, CKD, and CHF continued receiving Benzonatate 100 mg daily even after a pharmacy MRR recommended stopping the scheduled dose or changing it to PRN and the practitioner responded OK PRN. The order was not updated in time, and the resident kept getting the medication daily until it was later discontinued; the NHA said the follow-up process was lost during interim DON coverage.
A resident with COPD, bipolar disorder, oxygen dependence, moderate cognitive impairment, and hospice status received multiple pain and anxiety meds in a short span, including oxycodone, morphine, methocarbamol, and two lorazepam doses that were given too close together and at double the ordered dose. The MAR and controlled substance record showed the lorazepam was not administered per the physician order, and the facility did not document a licensed assessment or physician consultation before giving meds outside the ordered timing.
Mandatory QAPI training was not documented for 2 of 2 non-direct staff reviewed. Housekeeper-PP and Cook-QQ had records for resident rights, abuse/neglect/exploitation, infection control, and compliance & ethics, but surveyors could not locate QAPI training in their files. The NHA, DON, and Senior VP of Clinical Compliance & Quality discussed how in-services are assigned, and the Senior VP later stated QAPI training was not available for these staff.
A CNA did not have a current CNA Skills Competency Checklist on file to address areas of weakness. Surveyors reviewed the CNA’s competency record, found the last checklist was completed and signed in early 2024, and the NHA could not locate any newer competency or a policy for competencies.
Required postings for State agencies and advocacy groups were not fully displayed in an accessible location. Surveyors found that the Ombudsman, State Survey Agency, and APS postings lacked email addresses, several required agencies and programs were missing, and the statement advising residents that they may file a complaint with the State Survey Agency was not posted. During a resident group interview, residents were unaware of where the required information was located, and the NHA stated they were responsible for the postings.
A resident with MS and vision loss, who was cognitively intact, experienced an unwitnessed fall while transferring from the toilet in a private bathroom that lacked adequate support on the left side of the toilet. The resident reported using a right-side grab bar that caused shoulder pain and stated there was no left-side bar after a previously used left-arm support device was removed for being wobbly. Observation showed the bathroom had only a right-side grab bar and a non-skid strip placed too far from where the resident’s feet would rest while seated. A CNA stated the resident was supposed to call for assistance with transfers but was found on the floor between the toilet and sink, and the DON confirmed that a commode with handles had been removed and replaced with a raised toilet seat without further discussion of adding left-side support.
The facility failed to provide adequate supervision and interventions to prevent accidents for two residents. One resident sustained injuries during transfers due to improper handling and environmental hazards, such as exposed metal on a bed frame. Despite the care plan requiring specific assistive devices, staff did not consistently use them, leading to further injury. Another resident did not receive quarterly smoking assessments as required, potentially compromising their safety. These deficiencies highlight lapses in adherence to facility policies and care plans.
The facility failed to maintain an effective infection control program by inaccurately calculating infection rates and not adhering to hand hygiene policies during wound care. An LPN admitted to not calculating individual infection rates, complicating trend analysis. Additionally, an RN did not follow hand hygiene protocols while treating a resident's pressure injuries, as confirmed by the DON.
A resident was injured twice during transfers due to missing plastic caps on the metal bed frame, exposing sharp edges. The facility failed to conduct regular inspections, leading to the resident's leg being cut and an existing wound reopening. An audit revealed numerous beds with similar deficiencies, highlighting the facility's inadequate maintenance practices.
A resident with chronic pain syndrome experienced inadequate pain management at the facility. Despite severe pain reports, the facility failed to administer as needed pain medication consistently and did not offer sufficient non-pharmacological interventions. The resident's pain was not effectively managed, and staff did not collaborate with the healthcare team to adjust the pain management plan in a timely manner.
Failure to Prevent Worsening Pressure Injury and Infection
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care and prevention for a resident who was dependent for all ADLs, incontinent of bowel and bladder, and assessed as at risk for pressure injuries. The resident was admitted with cerebral palsy, deafness, and quadriplegia, and the care plan initially included interventions such as repositioning approximately every 2 hours, pressure-redistributing devices, and routine skin care. Despite these measures, the resident developed an abrasion to the right buttock shortly after admission, and the wound later deteriorated over time. The wound progressed from an abrasion to a worsening open area with increasing necrotic tissue. The record shows repeated deterioration, including measurements that reflected enlargement and increasing tissue breakdown. The resident’s care plan was updated several times to add interventions such as offloading the right hip/buttock, limiting time out of bed, and adding a gel cushion, but the wound continued to worsen. The resident later developed signs of infection in the wound and was treated with antibiotics. The resident was subsequently sent to the hospital because of necrosis in the wound. Hospital records documented that the wound was a stage 4 pressure injury after debridement and that infection was present, requiring surgical debridement, antibiotics, and a wound VAC on return to the facility. Later lab work again showed elevated inflammatory markers, and additional antibiotics were prescribed. Survey observations also identified concerns during wound care and incontinence care, including infection control issues and the resident not being offloaded after care. Staff interviews reflected conflicting information about whether the resident was noncompliant with repositioning, and the surveyor could not locate documentation supporting that claim.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility did not ensure that residents were free from accident hazards and provided adequate supervision to prevent accidents. Four sampled residents were involved in events where the facility did not maintain safety measures consistent with their assessed needs and documented care plans. The report describes unwitnessed falls with injuries, unsafe swallowing practices, and a suicidal statement made by a resident without documented safety interventions at the time of the incident. R34 was admitted with COPD, bipolar disorder, macular degeneration, legal blindness, and oxygen dependence, and later enrolled in hospice for COPD. Records showed increasing weakness, balance problems, restlessness, anxiety, poor decision-making, and altered mental status in the days before the fall. Staff documented that R34 was walking without the walker, searching for oxygen, and was difficult to redirect. R34 was found on the floor and sent to the hospital, where a left intertrochanter fracture was identified. The facility’s investigation determined that medication issues, including lorazepam not being administered as ordered and the combination of prescribed pain medication with altered mental status, contributed to the fall. R20 was admitted with CVA, right hemiplegia, aphasia, severe cognitive impairment, and hospice involvement. The record described impaired mobility, restlessness, and a need for frequent reminders and redirection for safety. R20 was found face down on the floor near the nurses’ station after an unwitnessed fall and was sent to the hospital with an open fracture of the right zygomatic arch. The facility later determined the wheelchair was not appropriate and that R20 had been leaning forward in the wheelchair before the fall. R32, who had Alzheimer’s disease and dysphagia, was observed drinking through a straw despite a physician order and care plan stating no straws. Dietary staff also placed a straw in the resident’s cup, and the resident coughed while drinking. R24 had diagnoses including diabetes, anxiety, and depression, with documented fall risk, impaired lower-extremity range of motion, and a history of repeated unwitnessed falls. The resident sustained 10 unwitnessed falls, and the report states the facility did not complete thorough investigations of each fall, with staff statements often missing or lacking detail about the resident’s condition and care before the falls. Several falls were associated with toileting attempts, transfers, or self-movement from bed, recliner, or wheelchair, and one fall resulted in nondisplaced fractures of the proximal phalanx of the right 4th and 5th toes. The report also documents that R24 made a suicidal statement about wanting a doctor to give a gun so the resident could shoot themself, and the facility did not document physician notification, increased supervision, or other safety measures at the time of the statement.
Food Stored on Freezer Floor
Penalty
Summary
Food was not prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. During an initial tour of the facility's main kitchen on 5/19/26 at 8:09 AM, a surveyor observed three opened cardboard boxes resting directly on the floor in the walk-in freezer. One box contained cookie dough, one contained turkey breast, and one contained containers of orange juice. The Wisconsin Food Code requires food to be stored in a clean, dry location and at least 6 inches above the floor to protect it from contamination. The Dietary Manager stated the facility follows Wisconsin Food Code for safe food practices. On 5/20/26 at 12:59 PM, the Dietary Manager said they were not sure why the opened boxes were on the freezer floor, and noted they had since been removed. The Dietary Manager stated the orange juice was intended to be returned to the supplier because it was the wrong type of juice, but did not know why the other two boxes were on the floor. The concern was shared with the Nursing Home Administrator and DON on 5/20/26 at 3:24 PM, and no additional information was provided.
QAPI Program Not Implemented as Written
Penalty
Summary
The facility did not implement policies and procedures for feedback, data collection systems, monitoring, and adverse event monitoring to develop activities to prevent adverse events potentially affecting 33 of 33 residents in the facility. The report states the facility also did not develop written documentation of performance improvement activities to help identify facility-wide problems, create plans to address identified issues, or maintain a system to monitor whether those plans were effective and revise them as needed. The facility policy titled Quality Assurance Performance Improvement (QAPI), dated 7/11/2022, describes a coordinated QA and PI program that is data-driven, involves all levels of the organization, and includes monthly QAPI meetings, PIPs, root cause analysis, action plans, and ongoing monitoring. The policy also states the Executive Director and DON are responsible for development, implementation, monitoring, and leadership of the QAPI program, and that QAPI minutes, monthly reports, and a PIP inventory are to be maintained. During interview on 5/26/2026, the NHA stated department heads meet monthly and the Medical Director attends at least quarterly, but the facility did not have any PIPs at that time. The NHA also stated the facility’s PIPs were not a formal process and nothing was in writing, although they had looked at changing some processes such as including immunizations in the admission packet and had previously looked at wound management. Surveyors identified multiple areas of concern, including immediate jeopardy for pressure injuries and significant medication errors, along with harm-level citations for quality of care and accidents, and the NHA stated QAPI had not identified those concerns.
Missing Behavioral Health Training for Multiple Staff
Penalty
Summary
Behavioral health training was not provided for 8 of 8 direct and non-direct staff selected at random. The staff members identified were LPN-OO, Housekeeper-PP, Cook-QQ, CNA-RR, CNA-SS, CNA-TT, CNA-MM, and CNA-UU. Record review showed each of these employees had completed other required training, such as resident rights, abuse, neglect, exploitation, infection control, QAPI, compliance and ethics, communication, and dementia for the CNAs, but surveyors were unable to locate behavioral health training for any of them. During the survey, staff explained that training was assigned through the facility's training system and that in-services were assigned monthly or as needed. The NHA stated she provided one-on-one or shift-to-shift training for other departments along with department heads, and the Senior VP of Clinical Compliance & Quality stated employee training was handled through the support center compliance department. When asked for the facility's training policy, the NHA stated the facility did not have one. The facility was not able to provide behavioral health training records for the 8 staff members reviewed.
Failure to Complete Required Background Checks Before Employment
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse by not ensuring criminal background checks were completed prior to employment for 4 of 8 employees reviewed. The deficiency was identified during interview and record review and was described as potentially affecting a pattern of the 33 residents in the facility at the time of the survey. The facility policy titled Abuse, Neglect and Exploitation required background, reference, and credential checks for potential employees and documentation showing the screening occurred. For RN-K, the facility could not provide background check documents completed at the time of hire. The records provided showed a BID, DOJ letter, and IBIS completed 21 months before the hire date, and later forms were dated more than 5 years after hire. The Nursing Home Administrator stated the facility could not produce the actual documents from the time of hire and did not know why the background check had been completed so far before employment. For LE-L, CNA-M, and CNA-N, the facility also could not provide required background check documents completed before employment. LE-L’s DOJ letter and IBIS were completed 4 months after hire, and the out-of-state background check was completed 15 months after hire. CNA-M’s DOJ letters and IBIS were completed 3 to 4 months after hire. CNA-N’s DOJ letter and IBIS were completed 15 months after hire. The NHA stated background checks had not been done for new employees prior to the NHA’s employment at the facility and agreed that the lack of timely background checks was a problem.
Insulin Pen Administration Competency Deficiency
Penalty
Summary
Licensed nurses did not demonstrate the competencies and skill sets necessary to care for a diabetic resident requiring insulin. The facility assessment stated that when the facility has not recently or previously managed a condition, staff education and competency validation will be completed, and the facility policy for subcutaneous insulin administration required specific steps for insulin pen use, including cleaning the rubber cap, performing a safety test/prime before each injection, and holding the injection button in place while slowly counting to 10 before withdrawing the needle. On 5/20/2026 at 12:20 PM, RN-P prepared to administer 12 units of Humalog insulin from a Kwik insulin pen to R30. RN-P screwed the needle onto the pen without cleaning the rubber seal first, did not know what priming an insulin pen meant until the surveyor explained it, and stated they had never heard of priming an insulin pen before. After the surveyor instructed RN-P on priming, RN-P administered the insulin, but let go of the plunger after the initial press rather than holding it down for a count of 10 seconds. RN-P also stated they may have had training on insulin pens when first hired but could not recall any specific training. Later that day, the surveyor shared these concerns with the NHA and DON, and the DON stated education would be provided to nursing staff.
Infection Control Lapses During Medication Pass, Wound Care, EBP Care, and Dining Room Storage
Penalty
Summary
The facility did not ensure a sanitary environment during medication administration, wound care, incontinence care, and use of enhanced barrier precautions. During morning medication pass, an RN prepared oral medications for a resident by punching each medication into the RN’s bare hand and then placing the pills into the medication cup. For stock medication, the RN removed the cap, poured pills into the RN’s bare hand, selected the ordered dose from the hand, and returned the remaining pills to the bottle. The facility policy for oral medication administration stated that tablets or capsules should be poured into the medication cup without touching the medication unless wearing gloves. A resident with cerebral palsy, deafness, quadriplegia, and dependence on staff for all ADLs, transfers, and bed mobility had a stage 4 pressure ulcer of the right ischium/buttock. During the wound treatment, one RN and another RN assisting with positioning performed multiple tasks without maintaining hand hygiene between dirty and clean activities. The wound care involved removing the dressing, cleansing the wound, handling clean wound vac supplies, cutting materials, and using scissors that were placed on the resident’s bed. One RN also touched the wound vac packaging, used the same gloves while struggling with the dressing, and at one point removed tape from the gloves with the mouth. During the same episode, the resident was incontinent, and the assisting RN performed incontinence care and then touched the resident’s call light, bed controller, and bedding with the same gloves before removing them. A resident on enhanced barrier precautions was observed being cleaned and transferred by two CNAs who were not wearing the required PPE for EBP and were only wearing gloves. One CNA cleaned the resident after a bowel movement, did not change gloves or perform hand hygiene after the task, then touched the resident’s sling and assisted with moving the resident in bed. After the transfer, the CNA discarded the soiled gloves without performing hand hygiene. In addition, an uncovered rack of unclaimed clothing was observed in the dining room throughout the survey, and staff stated the rack should not have been there.
Failure to Offer and Document Pneumococcal Immunizations
Penalty
Summary
The facility did not ensure pneumococcal immunizations were offered to 4 of 5 sampled residents reviewed for pneumonia immunizations. R4, R17, R20, and R22 were not current in their pneumococcal vaccination status, and the record review found no documentation that the vaccine was offered, administered, or declined. The facility policy titled Pneumococcal Vaccine (Series) states each resident is to be assessed for pneumococcal immunization on admission, offered the immunization unless medically contraindicated or already immunized, and documented if refused or contraindicated. For R4, R17, R20, and R22, survey review found no documentation showing they received the current pneumococcal vaccine or that they were provided information and declined it. The surveyor interviewed the DON and the RN infection preventionist, who stated immunization information should be in the resident medical record. The DON stated that R17 had a care conference where the immunization was declined, but there was no documentation of that conversation. The DON also stated the facility was working on a process to offer immunizations on admission by updating the admission packet so all immunization consents would be included.
Failure to Notify Physician of Resident’s Knee Pain and Swelling
Penalty
Summary
The facility did not ensure a resident’s physician was consulted after the resident reported mild left knee pain to Physical Therapy on 1/29/2026, and the resident continued to have left knee swelling without physician notification until 2/12/2026. The resident, R28, was admitted for therapy services after a hospital stay with influenza and had diagnoses including moderate cognitive impairment, no impairment in upper or lower extremities, dependence on staff for transfers, and no pain on the admission MDS. The facility policy on change in condition required immediate notification for acute or sudden onset symptoms or marked changes in symptoms. Record review showed that on 1/22/2026, RN-E documented that R28’s left leg got stuck under a wheelchair, causing pain, and staff were to monitor for swelling or increased pain to the left foot and ankle. However, the EHR did not show further monitoring related to that event, and survey review found no evidence of provider notification or documented monitoring after the incident. A 24-hour status report sheet listed R28 for monitoring of the left foot and ankle for swelling and increased pain, but there was no documented follow-up in the record. On 1/29/2026, a PT note by PTA-W documented that R28 reported mild left knee pain with observed swelling, and survey review found no documented evidence that therapy notified nursing staff of the concern.
Lack of Privacy During Wound Treatment
Penalty
Summary
The facility did not ensure privacy for 1 of 15 sampled residents during treatment and incontinence care. On 5/20/26 at 10:25 a.m., surveyors observed R14 receive wound treatment to the right buttock while the resident's window blinds remained open, with the window facing outside where people could possibly walk by and observe the care. RN-O performed the treatment with RN-P assisting by holding R14 on her left side. The blinds were not closed before or during the treatment, and RN-O and RN-P did not ask R14 if she wanted the blinds closed. R14 was admitted with cerebral palsy, deafness, and quadriplegia, and the quarterly MDS documented that R14 was cognitively intact and dependent for all ADLs, transfers, and bed mobility, with bladder and bowel incontinence. The window shade remained open throughout the wound treatment, including during incontinence care.
Unrepaired Room Damage in Residents' Rooms
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment for two sampled residents. R4, who was admitted with COPD, type 2 diabetes mellitus, anxiety disorder, and schizophrenia, had a large hole with plaster pushed in on the right side of the wall in the resident's room. The Quarterly MDS dated 3/12/26 showed a BIMS score of 11, indicating moderately impaired skills for daily decision making. Surveyors observed the damaged wall on 5/19/2026 and again on 5/26/2026, when it had still not been repaired. R4 stated the hole had been there for over a year and that it bothered the resident. The Maintenance Director acknowledged knowing about the hole for longer than he wanted to admit and stated it was one of the projects coming up; he also said he had been in every resident room but did not complete an organized routine audit of room conditions. R30, who was admitted with chronic kidney disease, type 2 diabetes mellitus, PTSD, bipolar disorder, and schizophrenia, had a large amount of paint missing on the right side of the wall in the resident's room. The MDS dated 4/2/26 showed a BIMS score of 15, indicating the resident was cognitively intact for daily decision making. Surveyors observed the missing paint on 5/20/2026, and R30 stated the condition had been reported to maintenance about a year earlier and was hard to look at and bothered the resident. On 5/26/2026, the Maintenance Director stated he had known about the missing paint for longer than he wanted to admit and that it was one of the projects coming up. The Nursing Home Administrator was informed that both room conditions had remained unrepaired for over a year and that both residents said the conditions bothered them.
Failure to Report Suspected Injury of Unknown Source
Penalty
Summary
The facility failed to ensure that a suspected injury of unknown source was reported to the state agency for 1 of 3 sampled residents reviewed for potential abuse concerns. A bruise and bump were discovered on the right forehead of a resident with Alzheimer's disease and paranoid personality disorder, and the quarterly MDS documented severe cognitive impairment. The resident was unable to state what happened, so the facility initiated an investigation into the cause of the injury. The investigation documented that the resident had a light blue bruise measuring 1.0 cm by 3.7 cm with a surrounding bump measuring 1.9 cm by 4.0 cm, and staff interviews were completed across shifts. The facility considered whether the injury may have occurred when the resident was combative during care and swinging her arms, or from contact with the mechanical lift bar, but the event was not reported to the state agency. The NHA stated the facility did not self-report because corporate colleagues believed the actions described by CNAs made the injury easily explained.
Bed-Hold Notices and Ombudsman Notifications Not Consistently Provided
Penalty
Summary
The facility did not ensure written notice of its bed hold policy was provided to residents and/or their representatives when residents were transferred to the hospital, and it did not consistently notify the State Long-Term Care Ombudsman of resident transfers and discharges. The facility policy stated that a notice of the resident’s bed hold policy should be provided to the resident and representative at the time of transfer, as possible, but no later than 24 hours after transfer, and that the social services director or designee would provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. For one resident, R7, who had moderately impaired cognition with a BIMS score of 12 and an activated healthcare POA, the record showed hospitalization for blood in stool, anemia, and thrombocytopenia, with return to the facility on 3/5/26. A bed hold request form documented phone confirmation from the POA to hold the bed, but the facility did not provide a written copy of the bed hold notice to the representative. The Social Services Coordinator could not provide evidence that the Ombudsman was notified of the hospitalization and stated the March and April 2026 monthly emails were forgotten. For another resident, R8, who had intact cognition with a BIMS score of 14 and an activated healthcare POA, the record showed hospitalizations for shaking and tremors with COVID, and later for back pain with urinary stones, with return to the facility on 1/18/26 and 3/24/26. Bed hold request forms documented phone confirmation from the POA, but the facility did not provide a written copy of the bed hold notice to the representative. The facility could provide evidence of Ombudsman notification for the January hospitalization but not for the March hospitalization, again stating the March and April 2026 monthly emails were forgotten. For R22, who was cognitively intact with a BIMS score of 13, the record showed transfer to the hospital for severe head and neck pain on 4/5/26 and return on 4/8/26. Although a Bed-Hold and Transfer Notice was signed and marked for hand delivery, the resident stated they did not recall receiving the notice or having the bed-hold policy explained, and the facility later acknowledged that the Ombudsman was not notified for the month of April 2026.
Care Plan Did Not Include Assessed Bed Rail Use
Penalty
Summary
The facility did not develop a comprehensive care plan based on assessment findings for one resident, R14. R14 was admitted with diagnoses including cerebral palsy and quadriplegia, and the quarterly MDS documented that she was cognitively intact, dependent for all ADLs, transfers, and bed mobility, and had bed rails used daily. The facility’s policy stated that the comprehensive care plan would be developed within 7 days after completion of the comprehensive MDS assessment and would describe services to be furnished and resident-specific interventions reflecting the resident’s needs and preferences. Survey review of R14’s care plan showed that the use of bed rails was not included. During interview, R14 stated that she uses the bed rails when being assisted with cares to roll from side to side. During observation of wound treatment, RN-O and RN-P repositioned R14 on her left side, and R14 did not use the bed rail. When interviewed, the DON stated that siderails should be included in the resident’s care plan when a resident uses them and has an assessment to use them.
Delayed Response to Resident Call Light for Toileting Assistance
Penalty
Summary
The facility did not ensure sufficient nursing staff was provided to answer a resident’s call light in a timely manner for toileting assistance. R37 was admitted with displaced intertrochanteric and subtrochanteric fractures of the right femur, required assistance of one staff member for transfers and toileting, and was continent of bowel and bladder. The resident’s BIMS score was 15, indicating intact cognition. The facility policy stated that all staff who see or hear an activated call light are responsible for responding, and that call lights should directly relay to staff or a centralized location to ensure appropriate response. On 5/20/26, the surveyor observed R37’s call light activated above the resident’s door at 8:05 AM. The call light remained unanswered while the surveyor observed staff walk past the room at 8:25 AM and again at 8:36 AM, including one staff member entering another resident’s room whose call light was not activated. At 8:20 AM, R37 stated, “I am going to s*** the bed, oh f***.” At 8:40 AM, two CNAs delivered meal trays to the hallway and one CNA finally responded to the call light, which had been unanswered for 35 minutes. R37 later stated that staff did not answer in time and the resident had to go in the brief, and also stated that toileting usually requires a commode and a lift to get out of bed.
Failure to Assess and Monitor Left Lower Extremity Injury
Penalty
Summary
The facility did not ensure appropriate treatment and care were provided for a resident with multiple sclerosis, dementia, weakness, and moderate cognitive impairment after the resident’s left leg became stuck under a wheelchair and caused pain. The resident’s record showed the resident had no pain and no extremity impairment on admission, but after the incident staff documented left foot and ankle swelling and pain monitoring only on the day of the event. The 24-hour status report sheets did not show ongoing monitoring beyond that initial day, and there was no documented evidence that a thorough assessment or continued follow-up of the left lower extremity occurred after the injury. Over the following weeks, nursing and therapy notes repeatedly documented left knee swelling, edema, and decreased function, including heavy cues needed for the lower left extremity and difficulty propelling the wheelchair. A therapy note also recorded mild left knee pain with observed swelling, and a nursing note later documented edema and swelling to the left knee and left lower extremity with no pain. Staff interviews indicated that concerns were often communicated verbally, but documentation of provider notification and monitoring was not found in the record. The DON stated there was no provider notification or monitoring after the incident and that immediate interventions, provider updates, and documented assessments were expected. The provider was not notified until the resident had progressive left lower extremity swelling, pain, and immobility, at which time a doppler ultrasound was ordered to rule out DVT. After the ultrasound was negative, the resident continued to have swelling and was later re-evaluated, when an x-ray was ordered at the family’s request. The x-ray showed a suspicious fracture of the left tibial plateau, and a repeat x-ray confirmed the fracture. Orthopedic follow-up later directed the resident to be non-weight bearing and therapy as tolerated.
Urostomy Supplies Not Available for Resident Care
Penalty
Summary
The facility did not ensure appropriate urostomy care and services for a resident who required them. The resident was admitted with a urostomy and diagnoses including weakness, multiple sclerosis, urinary tract infection, dementia, and acquired absence of other parts of the urinary tract. The admission MDS indicated the resident had an indwelling catheter and an ostomy. A progress note dated 1/22/2026 stated the resident’s family member would bring temporary urostomy supplies, and the 24-hour status report for 1/21/2026 through 1/30/2026 showed the resident still needed urostomy supplies on 1/23/2026. Surveyor interviews and record review showed the facility did not have the proper supplies available for the resident’s urostomy needs. Medical Records-F stated a box of 10 urostomy pouches was ordered on 1/20/26 and shipped on 1/26/2026, but they did not know when it was received. Medical Records-F also stated staff were supposed to write needed items on a sheet in the medication room, while urostomy supplies were kept in the med cart, which Medical Records-F could not access. The DON was unsure of the ordering process, and an agency LPN stated the facility did not always have the rubber wafer for the resident’s urostomy and relied on the resident’s wife to bring them in. The DON and NHA stated specialty needs should be identified before admission and that central intake was supposed to notify the facility of needed supplies, but sometimes that information was not relayed.
Failure to complete trauma assessments and individualized trauma-informed care plans
Penalty
Summary
The facility did not comprehensively assess 3 sampled residents for trauma and did not develop individualized trauma-informed care plans to identify triggers and prevent re-traumatization. The report states that the facility’s Trauma Informed Care policy required care and services to be delivered using approaches that are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The policy also required the facility to use a multi-pronged approach to identify trauma history, collaborate with the resident and others as appropriate, and add trigger-specific interventions to the care plan. For one resident, the record included a psychology progress note documenting severe depression and anxiety, grief over loss of independence, prior psychiatric hospitalizations, heavy alcohol use in the past, family history of suicide and mental illness, past suicidal ideation with contemplated firearm use, and military deployment during Navy service as a potential trauma history factor. The facility did not have documentation that a trauma assessment was completed, and the comprehensive care plan did not contain a focused problem with person-centered interventions for the traumatic events referenced in the psychology note. Staff interviewed during survey were not aware of the resident’s trauma history or what to do to prevent triggers. For a second resident, the trauma-informed care assessment was incomplete with 8 unanswered questions. The assessment documented beliefs that the resident’s sister was evil and that an old friend stole from the resident, and it noted that the resident was reminded of this experience when belongings were misplaced. However, the care plan did not identify the specific past event or include person-centered interventions to help de-escalate the resident if trauma-related responses occurred. Staff interviewed during survey were not aware of the resident’s trauma history or individualized triggers. For the third resident, the record showed diagnoses including PTSD, bipolar disorder, and schizophrenia, and a psychiatric follow-up note documented past psychiatric hospitalizations and significant trauma from discovering a son-in-law after his suicide, with PTSD related to an extensive history of trauma. The facility did not have a documented assessment beyond the psychiatric follow-up note to determine the extent of the trauma experienced. Although a trauma assessment was later completed, the care plan intervention remained generic and did not identify individualized triggers or responses. Staff interviewed during survey were not aware of the resident’s trauma history or triggers, and the social services coordinator stated they were far behind in reviewing psychology notes and needed psychology services to help develop focused problems for more difficult residents.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility did not ensure that residents received necessary behavioral health care and services to maintain the highest practicable mental and psychosocial well-being in accordance with their comprehensive assessments and plans of care. The deficiency involved 3 of 5 sampled residents reviewed for mood concerns: R2, R24, and R30. The report also states that on 5/26/2026, the Nursing Home Administrator told the surveyor that the facility did not have a policy and procedure for initiating behavioral health care and services. R2 was admitted with diagnoses including PTSD, major depressive disorder, paraplegia, end stage renal disease, morbid obesity, type 2 diabetes mellitus, and COPD. R2’s MDS dated 2/2/26 showed a BIMS score of 14 and no depressive symptoms or behaviors. During interview, R2 stated that R2 had been offered psychology services but wanted psychotherapy in person rather than by zoom. The Social Services Coordinator confirmed that the facility only offered zoom psychology services, made no attempt to provide in-person services, and that R2 had been trying to receive talk therapy at the facility but would not do zoom psychotherapy. R24 was admitted with diagnoses including type 2 diabetes mellitus, essential hypertension, anxiety disorder, and depression. R24’s MDS showed a BIMS score of 15 and a PHQ-9 score of 1, with documentation that R24 felt down, depressed, or had little interest or pleasure for 2-6 days. On 2/2/26, a progress note documented that R24 stated, "A doctor that will give me a gun so I can shoot myself in the head." The record review found no documentation that a suicidal evaluation was completed, no documentation that the physician was notified, and no focused care plan problem addressing suicidal ideation. The Social Services Coordinator stated that care plan focused problems were their responsibility, but also acknowledged not knowing why no care plans were in place and that an assessment had not been completed for the suicidal statement. R30 was admitted with diagnoses including chronic kidney disease, type 2 diabetes mellitus, PTSD, bipolar disorder, and schizophrenia. R30’s MDS dated 4/2/26 showed a BIMS score of 15 and no depressive symptoms or behaviors. A psychiatric follow-up note dated 10/31/25 documented past psychiatric hospitalizations and significant trauma, including PTSD related to extensive trauma. R30 told the surveyor that R30 had requested to see a therapist, but the facility did not do anything about it. The Social Services Coordinator confirmed that the facility was not providing in-person psychotherapy services, that R30 did not want zoom psychotherapy, and that the resident was never re-approached about arranging psychotherapy in the community or through the community case manager.
Failure to Provide Medically Related Social Services for Dialysis Transportation and Wheelchair Needs
Penalty
Summary
The facility failed to provide medically related social services to help a resident achieve the highest possible quality of life. The resident had diagnoses including PTSD, major depressive disorder, paraplegia, and end stage renal disease, and was cognitively intact with a BIMS score of 14. Therapy screened the resident and determined that a larger wheelchair was needed because the resident required a 24-inch-wide seat instead of a 22-inch-wide seat. The resident attended dialysis three times a week and had been using the same dialysis center for years, but the transportation company stated it could no longer transport the resident if a larger wheelchair was used because it would not fit on the ramp. The resident remained in a wheelchair that was too small and was broken, with both sides of the chair busted off. Survey observation showed the resident’s hips riding on the wheelchair wheels, and the resident stated the chair was uncomfortable and painful. Facility staff acknowledged that the larger chair had not been ordered because it would not fit on the current transportation vehicle. The resident told surveyors that the facility had known about the transportation issue since the fall and had told the resident to seek another placement with in-house dialysis, even though the resident did not want to leave the facility. The resident was crying during the interview and described being distressed about leaving, especially while also dealing with the husband’s terminal illness. Record review showed no social services documentation addressing the dialysis transportation problem, referrals, or the resident’s emotional well-being, and the discharge care plan had not been updated to reflect the possibility of transfer. Interviews with facility staff and the dialysis MSW showed that the facility had not actively resolved the transportation or placement issue and had relied on outside assistance for updates and referrals.
Failure to Act on Pharmacy MRR Recommendation
Penalty
Summary
The facility did not maintain procedures for acting on monthly drug regimen review recommendations for one resident. The resident had diagnoses including hypertensive heart and chronic kidney disease, anxiety, and chronic diastolic congestive heart failure. A pharmacy medication regimen review dated 1/21/26 documented that Benzonatate 100 mg daily had been ordered since 8/22/25 for cough and recommended discontinuing the scheduled dose and changing it to PRN. The review also noted that Benzonatate is generally used for short-term treatment of cough and that long-term use has a narrow therapeutic window and a high risk of adverse effects. The resident’s ordering practitioner responded “OK PRN” on 2/11/26, but the surveyor could not locate evidence that the order was changed to PRN as recommended. The resident continued receiving scheduled Benzonatate 100 mg daily until it was discontinued on 3/4/26. During interview, the NHA stated the DON would normally follow up on physician responses to pharmacy MRRs and update resident orders, but the process was lost during a period with interim DONs. The DON stated the missed order was known, but the DON was not working at the facility in March 2026.
Unnecessary Daily Benzonatate Continued After PRN Recommendation
Penalty
Summary
Each resident's drug regimen was not kept free from unnecessary drugs for 1 of 5 residents reviewed, R7. R7 was admitted with diagnoses including hypertensive heart and chronic kidney disease and chronic diastolic heart failure. A pharmacy medication regimen review dated 1/21/26 identified that R7 was receiving Benzonatate 100 mg daily since 8/22/25 for cough and noted that the medication is generally intended for short-term use. The pharmacist recommended discontinuing the scheduled order or changing it to PRN because of the risk of adverse effects with long-term use. The ordering practitioner responded "OK PRN" on 2/11/26, but R7 continued to receive Benzonatate 100 mg daily through 3/1/26, and the physician order remained documented as daily until it was discontinued on 3/4/26. The facility's NHA stated the process for following up on physician responses to pharmacy MRRs was lost during leadership changes, and that the DON or ADON would normally update resident orders after physician recommendations. The DON acknowledged the order was missed, and no additional information was provided.
Significant Medication Error Involving Multiple PRN and Scheduled Drugs
Penalty
Summary
The facility did not ensure that one resident was free from significant medication errors. The resident had diagnoses including COPD, bipolar disorder, and dependence on supplemental oxygen, and the record also documented moderate cognitive impairment and hospice enrollment for COPD. On the evening of the event, the resident received multiple medications in a short time span, including methocarbamol, oxycodone, morphine, and two doses of lorazepam that were given too close together and not according to the physician order for lorazepam 0.5 mg every 4 hours PRN. The medication administration record showed lorazepam was administered at 8:23 p.m. and again at 9:21 p.m., and the controlled substance record documented that two tablets were removed from the medication pack instead of one for each administration, resulting in the resident receiving double the ordered dose each time. The resident also received morphine at 7:51 p.m. and then a scheduled morphine dose at 10:00 p.m., without documentation that the facility clarified whether the doses could be given closer than the ordered 4-hour interval. The medication error report stated the nurse who administered the lorazepam said the resident kept asking for it and she felt the resident needed it. After the resident’s fall, the facility identified the medication error during review of the MAR and documented that the resident had received two doses of lorazepam approximately 2 hours and 15 minutes apart, which was too frequent compared with the order. Surveyor review also noted the facility did not document an assessment by licensed staff and consultation with the physician before giving medications outside the prescribed parameters. The resident was found on the floor with the head by the bed and legs toward the recliner, and was sent to the hospital shortly afterward.
Failure to Provide QAPI Training to Non-Direct Staff
Penalty
Summary
Mandatory training on the facility’s QAPI Program was not provided to 2 of 2 non-direct staff reviewed. Housekeeper-PP, hired 3/28/25, had training records showing resident rights and responsibility, abuse, neglect, exploitation, infection control, and compliance & ethics, but surveyor was unable to locate any QAPI training. Cook-QQ, hired 4/27/21, also had records showing resident rights and responsibility, abuse, neglect, exploitation, infection control, and compliance & ethics, but surveyor was unable to locate QAPI training in the 2025-2026 training records. On 6/3/26, the surveyor requested training records for Housekeeper-PP and Cook-QQ and later met with the NHA-A, DON-B, and Senior VP of Clinical Compliance & Quality-VV to ask how in-services are assigned and who is responsible for training non-nursing staff. NHA-A stated in-services are assigned monthly and additional training is assigned as needed, and that she provides one-on-one or shift-to-shift training with other departments along with department heads. Senior VP of Clinical Compliance & Quality-VV stated employee training is through the support center compliance department for required trainings, and later informed the surveyor that QAPI training was not available for Housekeeper-PP and Cook-QQ.
Missing Current CNA Skills Competency Checklist
Penalty
Summary
The facility did not ensure that 1 of 5 randomly sampled CNAs had a current CNA Skills Competency Checklist completed to address areas of weakness. CNA-TT’s last CNA Skills Competency Checklist was completed on 1/1/24, and the checklist was signed by CNA-TT and the prior DON on 1/4/24. On 6/3/26, the surveyor requested competencies for five randomly selected CNAs from the NHA and DON and was provided CNA-TT’s competency checklist, which showed the 1/1/24 completion date. When the surveyor asked whether there was a current competency, the NHA stated they could not locate another competency. When asked about a policy for competencies, the NHA later stated they did not have a competency policy.
Required State Agency and Advocacy Postings Not Accessible or Complete
Penalty
Summary
The facility did not ensure that required contact information for pertinent State agencies and advocacy groups was posted in an area accessible to residents and staff. Surveyors observed that the facility’s postings were located behind a glass cabinet on the left wall when entering the facility and were not located in any other area. The posted information for the State Survey Agency, Ombudsman, and Adult Protective Services did not include email addresses, and required information for the Protection and Advocacy Network, Home and Community Based Service Programs, Family and Medical Leave Act, Medicaid Fraud Control Act Unit, and Applying for Medicare and Medicaid was not posted. Surveyors also found that the required statement informing residents that they may file a complaint with the State Survey Agency concerning suspected violations of state or federal nursing facility regulations was not posted, including information related to resident abuse or neglect, non-compliance with advanced directives requirements, and requests for information regarding returning to the community. During a group interview, all six residents in attendance stated they were not aware of where facility-required resident information was posted, and five residents did not know what an Ombudsman was or where Ombudsman information was located. The Nursing Home Administrator stated they were responsible for the postings but had no further explanation for why the required information was not posted in an easily accessible location.
Failure to Provide Adequate Toilet Transfer Supports and Safe Bathroom Environment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s bathroom environment was free from accident hazards and that adequate supports were provided to prevent accidents during toilet transfers. The resident was admitted with multiple sclerosis and vision loss, and the admission MDS showed she was cognitively intact with no falls since admission. On the date of the incident, progress notes documented that the resident was found in a private bathroom sitting on her buttocks between the toilet and sink, stating she had been getting off the toilet, lost her balance, and fell, striking her left shoulder on the sink. A subsequent note indicated the fall was unwitnessed and that the resident, who was on Eliquis, was sent to the hospital after reporting she had hit her head. During interviews, a CNA confirmed the resident was expected to call for assistance with transfers, but the resident was found on the floor when the CNA entered with a lunch tray. The resident reported that in the bathroom where the fall occurred, there was only one grab bar on the right side of the toilet, which she used but which caused shoulder pain, and there was no bar on the left side to support her left arm. She also stated she is blind and has leg weakness due to MS. Observation of the prior bathroom showed a non-skid strip on the floor in front of the toilet, but it was placed too far from where her feet would be while seated. In the current bathroom, there was a toilet riser and a right-side grab bar, but no left-side support, and the resident reported that a prior left-arm support device had been removed because its legs were wobbly, leaving her without left-side support. The DON confirmed that a commode with handles over the toilet had been removed due to being wobbly and replaced with a raised toilet seat, and acknowledged there had been no discussion about adding left-side support after that change.
Inadequate Supervision and Environmental Hazards Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure adequate supervision and interventions to prevent accidents for two residents, R26 and R29. R26 sustained injuries during transfers on multiple occasions due to improper handling and environmental hazards. On one occasion, R26's leg was injured due to a missing cap on the bed frame, exposing sharp metal edges. Despite the facility's policy on safe resident handling, staff did not consistently use the required assistive devices, such as a 2-wheel walker and gait belt, during transfers. This lack of adherence to the care plan and failure to address environmental hazards contributed to R26's injuries. R26, who is cognitively intact and has impairments in bilateral lower extremities, experienced significant pain and skin tears due to these incidents. The facility's documentation revealed that R26's care plan required assistance from two staff members using a walker and gait belt for transfers. However, observations showed that staff did not follow these guidelines, leading to further injury. Additionally, the facility's audits identified missing plastic pieces on bed frames, which posed a risk to residents, including R26. For R29, the facility failed to conduct quarterly smoking assessments as required by their policy. R29, who is cognitively intact and has significant physical impairments, was determined to be independent with smoking. However, the last smoking assessment was completed several months prior, and the facility did not provide a valid reason for the oversight. This lack of regular assessment could have compromised R29's safety, as the facility's policy mandates regular evaluations to determine the need for supervision during smoking activities.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by inaccurate calculation of total infection rates and individual infection types. The Licensed Practical Nurse (LPN) in charge of the infection control program admitted to not calculating individual rates of infection and including infections from previous months and chronic infections in the monthly totals. This practice made it difficult to analyze data for trends or increases in infection rates. The facility's infection surveillance policy required monthly data capturing and reporting to monitor trends, but the facility did not adhere to this policy, as evidenced by the review of monthly infection rate surveillance summary reports. Additionally, a deficiency was observed in the hand hygiene practices during wound care for a resident with unstageable pressure injuries. The Registered Nurse (RN) performing the wound care did not follow the facility's hand hygiene policy, which required hand hygiene after handling contaminated objects and before and after applying personal protective equipment. The RN failed to perform hand hygiene after removing soiled gloves and before donning new gloves during the treatment of the resident's wounds. This was confirmed by the Director of Nursing (DON), who observed the procedure and acknowledged the deviation from the facility's policy.
Failure to Inspect and Maintain Bed Frames Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure proper inspection and maintenance of resident beds, leading to injuries for a resident during transfers. On two separate occasions, the resident was injured due to missing plastic caps on the metal bed frame, which exposed sharp edges. The first incident occurred when the resident hit their leg on the bed frame, resulting in a deep skin tear that required emergency medical attention. The facility's documentation identified the missing cap as the root cause of the injury, and a temporary fix was applied by using a part from another bed. Despite the initial incident, a second injury occurred when the resident's existing wound reopened after making contact with the metal bed frame during a transfer. This incident highlighted the ongoing issue of missing caps, as an audit revealed numerous beds with similar deficiencies. The facility's maintenance director admitted that the inspection process did not initially include checking for missing end caps, and it was only after the incidents that this became a focus. The facility's failure to conduct regular and thorough inspections of the beds contributed to the resident's injuries.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as R26, who was admitted with diagnoses including Polyneuropathy, anxiety, and Chronic Pain Syndrome. Despite being on a scheduled pain medication regimen, R26 experienced frequent and severe pain, which was not effectively managed. The facility did not administer as needed pain medication on certain dates and failed to offer non-pharmacological interventions consistently. R26 reported significant pain levels, which interfered with daily activities and mobility, yet the facility did not adequately address these complaints or adjust the pain management plan in a timely manner. The facility's policy on pain management was not followed, as staff did not incorporate non-pharmacological interventions into R26's care plan, nor did they notify the healthcare practitioner when pain medications were ineffective. R26 expressed to the surveyor that the pain was severe, reaching a 10 out of 10 on the pain scale, and described it as stabbing pain. Despite these reports, the facility's response was inadequate, with limited interventions such as elevating the leg and delayed implementation of an ice pack. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, revealed a lack of collaboration with the healthcare team to adjust R26's pain management plan. The facility's documentation showed that pain medications were often ineffective, yet there was no evidence of timely communication with the physician or implementation of alternative pain management strategies. The deficiency was highlighted when the surveyor noted that new interventions were only initiated after concerns were raised during the survey.
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What surveyors actually found near you
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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.
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Nursing homes near Williams Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delavan Health Services | 5.6 mi | ★★★★★ | 0 | 0 |
| Geneva Lake Manor | 6.2 mi | ★★★★★ | 12 | 2 |
| Golden Years Of Lake Geneva | 7 mi | ★★★★★ | 0 | 0 |
| Holton Manor | 7.1 mi | ★★★★★ | 19 | 0 |
| Lakeland Health Care Ctr | 7.1 mi | ★★★★★ | 5 | 0 |
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