Eden Rehab Suites And Green House Homes
Inspection history, citations, penalties and survey trends for this long-term care facility in Oshkosh, Wisconsin.
- Location
- 3151 Eden Ct, Oshkosh, Wisconsin 54904
- CMS Provider Number
- 525704
- Inspections on file
- 15
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Eden Rehab Suites And Green House Homes during CMS and state inspections, most recent first.
A resident with intact cognition and a history of acute and chronic respiratory failure with hypoxia and COPD requested a copy of their medical record in writing, with a family member also involved in the request. The NHA received the email requests and indicated the facility had up to 30 days to respond, while the SW was unsure of the required timeframe. The DON reported there was no specific policy for handling medical record requests. Although the NHA had a paper copy of the record and was planning an internal review meeting before release, the resident had not received the requested records within the required timeframe, resulting in a deficiency for failure to provide timely access to medical records.
A hospice patient with metastatic cancer, chronic pain, and a stage 4 pressure ulcer repeatedly reported pain at 9–10/10, became verbally aggressive, and requested IV pain medication that the facility could not provide. Staff believed the resident had received the maximum scheduled and PRN pain medications and, after the resident agreed to go to the hospital, an RN notified the DON and arranged transfer to the ER without first notifying hospice, and did not initially notify the POAHC. The hospice agency later reported it had not been informed of the resident’s escalating pain or behavior before the day the resident was sent to the ER, and stated the resident’s pain regimen could have been adjusted.
Two residents were transferred to the hospital and did not receive proper written bed-hold and transfer/discharge notices with required appeal rights information. One resident with metastatic cancer, chronic pain, a stage 4 pressure ulcer, and moderate cognitive impairment, represented by an activated POA, was told by the admissions staff that the resident was being kicked out and would not be allowed to return, and neither the resident nor the POA received any written bed-hold or transfer/discharge notice. Another resident with acute on chronic combined systolic and diastolic CHF and aspiration pneumonia, who was cognitively intact and made their own healthcare decisions, signed a bed-hold/transfer form that lacked mandated appeal rights details, including contact information for the appeals entity and instructions on obtaining and submitting an appeal. The DON acknowledged that the facility used the bed-hold form as its policy, had no separate policy, and was unaware of the requirement to include appeal rights on these notices.
Staff failed to follow facility policy and MD orders for respiratory care when a resident with COPD, acute and chronic respiratory failure with hypoxia, acute pulmonary edema, and heart failure received nebulizer treatments. Although the MAR showed that nebulizer treatments were given and the resident self-administered them after nurse set-up, nursing staff did not consistently assess or document required pre- and post-treatment parameters such as lung sounds, pulse, respirations, and oxygen saturation as directed. The DON confirmed that nebulizer assessments should be documented on the MAR and that this was not consistently done for this resident.
A hospice resident with metastatic cancer, chronic pain, and opioid dependence experienced uncontrolled pain rated 10/10 despite having both scheduled and PRN morphine and adjunctive medications ordered. CNAs and the DON reported the resident repeatedly requested pain medication, exhibited distress and behavioral changes, and refused some non-pharmacologic interventions and assessments. The RN administered scheduled and one PRN morphine dose, documented it as effective despite ongoing aggressive behavior, and reported offering additional PRN morphine later, but the medical record showed no documentation of further offers or refusals and confirmed that more PRN morphine could have been given before the resident was transferred. Facility staff told hospice and the hospital that the resident had “maxed out” on pain medications and was being sent to the ER for uncontrolled pain and behavior, while hospice reported the resident had not reached maximum dosing and that the facility declined hospice’s offer to assess and adjust the pain regimen before transfer.
Surveyors found that the facility failed to maintain sanitary conditions in the kitchen, including a microwave with dried food debris, improperly stored and outdated food items in the refrigerator, and a dishwasher that did not reach the required sanitizing temperature. These deficiencies were observed during a kitchen inspection and had the potential to affect all residents.
Two residents with activated POAHC due to incapacity had healthcare decisions made or consents signed by individuals not authorized as their healthcare agents. In one case, a family member not listed in the POAHC made decisions, and in another, the incapacitated resident signed their own medical consents instead of the designated agent. Staff confirmed these actions were not in accordance with facility policy or state law.
A resident with Alzheimer's disease, moderate cognitive impairment, and mobility needs was repeatedly observed with their call light out of reach while in bed. The resident was unable to access the call light when needing assistance, and staff confirmed the device was not accessible as required by facility policy.
The facility did not ensure timely and accurate completion of PASRR Level I and Level II screenings or obtain required county exemption forms for three residents with mental illness diagnoses and/or prescribed psychotropic medications. PASRR documentation was not updated to reflect medication changes, and necessary screenings were not submitted when residents remained in the facility beyond 30 days.
Two residents did not receive timely and appropriate assistance with ADLs. One resident with a large perirectal wound was left in urine or stool for extended periods due to delayed call light response and inadequate incontinence care, while another resident discharged from PT did not receive the recommended restorative ambulation program, with staff unaware of the walking schedule and the care plan lacking this intervention. Facility policies requiring timely response and maintenance of ADL abilities were not followed.
Multiple residents with cognitive impairment and a history of falls experienced repeated unwitnessed falls without thorough investigation, root cause analysis, or updates to their care plans. Required neurological checks were often incomplete or missing, and the facility did not consistently follow its own fall procedures. The DON confirmed that fall investigations, care plan updates, and neuro checks were not properly completed after these incidents.
Surveyors observed that two residents with indwelling medical devices did not receive care in accordance with infection control and Enhanced Barrier Precautions (EBP) policies. During perineal care, staff failed to perform hand hygiene between glove changes, did not wear required gowns, and did not ensure EBP signage or PPE carts were present. Staff and nursing leadership confirmed these actions did not meet facility policy requirements.
The facility failed to complete ordered wound care for two residents, leading to immediate jeopardy for one. A resident with Charcot's foot did not receive daily dressing changes, resulting in maggots in the wound and hospital transfer. Another resident's dressing change was missed, with no documentation of completion. The deficiencies were due to lapses in following prescribed wound care regimens.
The facility did not ensure food was stored and prepared in a sanitary manner, with items in the kitchen cooler not listed on the cooling log and kitchenettes found in unsanitary conditions. The Dietary Manager confirmed that the facility's process for documenting food cooling temperatures and daily cleaning of kitchenettes was not being followed.
A resident with severe cognitive impairment and multiple diagnoses experienced several falls resulting in injuries due to the facility's failure to implement fall prevention interventions as outlined in the care plan. Observations revealed the bed was not in the lowest position and the floor mat was not in place, despite these measures being required.
Failure to Provide Timely Access to Requested Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to provide timely access to a resident’s medical record after a written request. A resident with intact cognition, as evidenced by a BIMS score of 15/15 on an MDS assessment dated 12/10/25, had been admitted with diagnoses including acute and chronic respiratory failure with hypoxia and COPD with acute exacerbation, and was discharged on 12/10/25. The resident and a family member submitted a written request for the resident’s medical record to the Nursing Home Administrator via email on 1/20/26, followed by a signed formal request sent via email on 1/22/26. As of 2/5/26, the resident had not received the requested records. The family member reported that the NHA responded by email stating the facility had up to 30 days to provide the records. During interviews, the DON stated the facility did not have a policy for medical record requests and instead followed state and federal regulations. The Social Worker acknowledged awareness of the resident’s request but was uncertain of the required timeframe for releasing records, estimating it to be 48 hours. The NHA showed the surveyor a paper copy of the resident’s medical record and stated that a meeting to review the records, originally planned for 2/4/26, had been postponed to 2/6/26, and that the NHA intended to call the resident after the meeting to inform them the records were ready for pickup. Despite the request and internal awareness of it, the records had not been provided to the resident within the required timeframe, resulting in the deficiency related to timely access to medical records.
Failure to Notify Hospice of Uncontrolled Pain Prior to Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a hospice agency in a timely manner about a resident’s uncontrolled pain and escalating behavior. The resident was admitted on hospice services with multiple serious diagnoses, including metastatic prostate cancer to the bone, a stage 4 right heel pressure ulcer, osteomyelitis, cervical radiculopathy, chronic pain, peripheral neuropathy, and opioid dependence. The resident’s cognition was assessed as modified independent, and a Power of Attorney for Healthcare (POAHC) had been activated. Staff interviews and record review showed that the resident repeatedly reported pain at 9–10 out of 10, requested IV pain medication that the facility could not provide, and became verbally aggressive and impatient with call light response times. The Admissions Coordinator reported being informed that the resident had “maxed out” on pain medications and still had pain at 10 out of 10, and stated that hospice and family were notified that the resident’s pain remained uncontrolled and that the resident was requesting more pain medication than the facility could provide. However, the Hospice Director of Clinical Services stated hospice had not received any reports of uncontrolled pain or escalating verbally aggressive behavior prior to the morning when the Nursing Home Administrator and Admissions Coordinator informed hospice that the resident’s pain was 9–10 out of 10 and that the resident was being sent to the ER. The Hospice Director also stated the resident had not actually “maxed out” on pain medication and that medications could have been adjusted. The DON reported that the RN had given all pain medication the resident could have per facility understanding, found it ineffective, notified the on-call provider, and sent the resident to the ER, but could not recall if hospice was contacted before the transfer. The RN confirmed not notifying hospice prior to sending the resident to the hospital, stating the resident’s mind was made up about going to the hospital, and also verified not initially notifying the POAHC. The resident was sent to the ER and later died in the hospital.
Failure to Provide Required Bed-Hold and Transfer/Discharge Notices With Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices, including appeal rights information, to residents who were transferred to the hospital. For one resident (R2), who had metastasized prostate cancer, a stage 4 pressure ulcer to the right heel, opioid dependence, spinal stenosis of the cervical region, chronic pain, and moderate cognitive impairment, the record showed a hospital transfer on 1/23/26 due to chronic pain and refusal of care. R2 had an activated POA assisting with healthcare decisions. Interviews with the POAs indicated that the Admissions Coordinator informed them that R2 was being kicked out and would not be allowed to return because of complaints of pain, behaviors, refusal of care, uncontrolled pain, and combative behavior. The medical record did not contain any written bed-hold or transfer/discharge notice for R2 or the POAs, and the Admissions Coordinator confirmed that no such notice or discussion occurred. The DON confirmed that no bed-hold or transfer/discharge notice was reviewed or provided because the facility would not accept R2 back and stated unawareness of the requirement to provide such notices, including information on return rights and appeal rights, for all residents transferred to the hospital. For another resident (R13), who had acute on chronic combined systolic and diastolic congestive heart failure, aspiration pneumonia, and intact cognition with responsibility for their own healthcare decisions, the record showed a hospital transfer on 2/1/26. R13’s signed “Bed-Hold for Hospitalization and Therapeutic Leave/Discharge” form was present but lacked required information on appeal rights. Specifically, the form did not include the name, mailing and email address, and telephone number of the entity that receives appeal requests, nor did it provide information on how to obtain an appeal form or receive assistance with completing and submitting an appeal hearing request. The DON stated they were not aware that bed-hold and transfer/discharge notices must include information on appeal rights and verified that the facility’s form did not contain the required appeal information. The DON also indicated that this same form functioned as the facility’s policy and that there was no separate bed-hold or transfer/discharge policy.
Failure to Perform and Document Required Respiratory Assessments for Nebulizer Treatments
Penalty
Summary
Staff failed to provide and document required respiratory assessments in connection with nebulizer treatments for one resident. The facility’s Respiratory policy dated 1/2025 requires qualified nursing staff to assess a resident’s pulse, oxygen saturation, and lung sounds prior to nebulizer administration, and to reassess pulse, oxygen saturation, minutes of nebulizer use, and lung sounds after administration, with all respiratory nursing documentation to include pre- and post-nebulizer treatment assessments. The resident involved had physician orders to self-administer nebulizers and an inhaler after nurse set-up three times daily, and a specific order to assess prior to administering nebulizer treatment and to document lung sounds, pulse, and respirations every six hours for COPD. The Medication Administration Record (MAR) showed that all nebulizer treatments were provided, but the ordered nebulizer assessments were not completed as required. The resident was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, acute pulmonary edema, and heart failure, and had a BIMS score of 13/15, indicating intact cognition, with an activated POA for healthcare. Despite the resident’s respiratory conditions and the clear policy and physician orders, staff did not assess the resident’s lungs prior to set-up or after the self-administered nebulizer treatments, and these assessments were not consistently documented in the MAR. During interview, the DON confirmed that nebulizer assessments should be documented in the MAR and verified that the resident’s nebulizer assessments were not consistently documented, confirming the failure to follow the facility’s respiratory policy and the physician’s orders for respiratory assessment and documentation.
Failure to Collaborate With Hospice and Fully Utilize Ordered Analgesics for Severe Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management to a hospice resident with metastatic prostate cancer, a stage 4 heel pressure ulcer, osteomyelitis, chronic pain, peripheral neuropathy, cervical radiculopathy, and opioid dependence. The resident had moderate cognitive impairment and an activated healthcare power of attorney. Facility policy required systematic recognition, assessment, treatment, and monitoring of pain, including use of appropriate pain assessment tools, observation of non-verbal indicators, collaboration with the prescriber and hospice, and reassessment and adjustment of medications when pain was not controlled. On the night shift prior to the event, the resident’s pain was documented as 0, but on the following morning shift the pain level was documented as 10 out of 10. On the morning in question, CNAs reported that the resident repeatedly requested pain or gas medication, was rude and demanding, and later was found balled up and non-verbal. Another CNA reported the resident stated they were waiting for pain medication, continued to report severe pain, refused breakfast, and declined non-pharmacological interventions such as an ice pack and repositioning. The DON stated the resident refused assessments on admission and again that morning, while reporting pain at 10 out of 10. The DON also stated that the assigned RN had provided all pain medication the resident could receive and that the pain remained at 10 out of 10, leading to a decision to send the resident to the ER for intractable, uncontrolled pain. However, review of the MAR with the DON showed that additional PRN morphine could have been administered before the transfer time, and the record did not show any documentation that PRN morphine was offered and refused after the 7:01 AM dose. The hospice Director of Clinical Services reported being told by facility staff that the resident had “maxed out” on scheduled and PRN pain medications and was being sent to the ER, but hospice determined the resident had not actually reached the maximum allowable pain medication. Hospice stated they could have assessed the resident and adjusted or increased pain medications, and offered to involve the hospice medical director and send a nurse, but the facility declined and proceeded with the ER transfer. The hospital case manager reported being informed that the resident was being sent back due to pain control and behavior concerns and that hospice had offered solutions which the facility declined. The RN caring for the resident stated the resident complained of pain everywhere at a level 10 out of 10, requested IV pain medication and higher doses of opioids than the facility could provide, and that scheduled and PRN morphine were given close together. The RN documented the PRN morphine as effective despite the resident’s continued aggressive behavior and reported offering additional PRN morphine later, but this offer and any refusal were not documented in the medical record. Hospice later reported that the resident’s hospitalization would not have been necessary had hospice been involved in managing the resident’s pain prior to transfer.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage and preparation practices during an inspection. The kitchen microwave was found to have dried food debris on the interior surfaces, indicating it was not cleaned in accordance with the facility's policy or the Wisconsin Food Code, which requires daily cleaning of microwave cavities and door seals. The Dietary Manager confirmed that the microwave should be cleaned after each use, but it was not cleaned until after the surveyor's observation. In the main kitchen refrigerator, surveyors observed a partially open container of marinara sauce that was past its use-by date and had not been discarded as required. Additionally, a package of celery was found open to air with an open date well beyond the recommended consumption period and without a use-by date. These findings demonstrate that the facility did not consistently follow proper food labeling, storage, and discard procedures as outlined in the Wisconsin Food Code and the facility's own policies. The facility's dishwasher was also found to be deficient. The machine failed to reach the minimum required rinse temperature of 180 degrees Fahrenheit, as indicated on the manufacturer's data plate and required by the Wisconsin Food Code. Despite multiple attempts to run the machine and intervention by the Maintenance Director, the rinse temperature remained below the required threshold, raising concerns about the effectiveness of dish sanitization. These deficiencies had the potential to affect all 35 residents residing in the facility.
Failure to Ensure Healthcare Decisions Made by Properly Delegated Representatives
Penalty
Summary
The facility failed to ensure that the right to make healthcare decisions was exercised only by individuals properly delegated by the resident, in accordance with applicable law, for two residents. In the first case, a resident with moderate dementia and an activated Power of Attorney for Healthcare (POAHC) had a designated agent who resigned. The facility allowed a family member, not listed as a healthcare agent in the POAHC document, to make healthcare decisions and sign medical consents for the resident. Staff interviews confirmed that the family member was not authorized to act as the healthcare agent, and the alternate agent listed in the POAHC was not contacted or involved. In the second case, another resident with moderate cognitive impairment and an activated POAHC was admitted with documentation confirming incapacity and the activation of their healthcare agent. Despite this, the facility had the resident, who was deemed incapacitated, sign multiple healthcare consent forms, including medication consents, a CPR directive, and a vaccine consent. Staff confirmed that the resident's POAHC should have been the one to sign these documents, not the resident themselves. Both incidents demonstrate that the facility did not follow its own policy or state law regarding the delegation of healthcare decision-making authority when a resident is deemed incapacitated. The facility failed to ensure that only the designated healthcare agent, as specified in the POAHC, was making or authorizing healthcare decisions for these residents.
Call Light Inaccessibility for Resident with Cognitive and Physical Impairments
Penalty
Summary
A deficiency occurred when a resident's call light was not accessible while the resident was in bed, contrary to the facility's policy requiring call lights to be within reach. The resident, who had Alzheimer's disease, a history of urinary tract infections, moderate cognitive impairment (BIMS score of 9/15), and required assistance with transfers, ambulation, and toileting, was observed multiple times over the course of a morning with the call light lying on the floor approximately five feet from the bed. The resident used a wheelchair and walker and had an activated Power of Attorney for Healthcare. During interviews and observations, the resident indicated an inability to locate or reach the call light when needing to use the bathroom. Staff confirmed the call light was not accessible and acknowledged that it should always be within reach for all residents, as per facility policy. The Director of Nursing also confirmed that the call light should have been accessible at all times.
Failure to Ensure Timely and Accurate PASRR Screening and Documentation
Penalty
Summary
The facility failed to ensure compliance with Pre-admission Screening and Resident Review (PASRR) requirements for three residents with mental illness (MI) diagnoses and/or prescribed psychotropic medications. For these residents, the facility did not update PASRR Level I Screens to reflect changes in prescribed medications and did not submit timely PASRR Level II Screens when the residents remained in the facility beyond 30 days. Additionally, the facility did not obtain required county exemption forms (DHS form F-20822) upon admission for these residents. One resident with major depressive disorder and moderate dementia was admitted with a PASRR Level I Screen indicating MI and psychotropic medication use, but the screen was not updated when medications changed, and a Level II Screen was not submitted in a timely manner. Another resident, admitted with a diagnosis of acute respiratory failure but prescribed psychotropic medications for depression and anxiety, had a PASRR Level I Screen marked for MI and a 30-day hospital exemption, but the Level II Screen was not submitted until after the resident remained in the facility past 30 days. The required county exemption form was also not provided at admission. A third resident with a history of depression and OCD with skin picking was prescribed multiple psychotropic medications, but the PASRR Level I Screen did not reflect all current medications or MI diagnoses. The facility did not update the Level I Screen with new medications, did not submit a Level II Screen, and did not provide the county exemption form. Throughout the survey, the facility was unable to provide complete PASRR documentation or exemption forms for these residents despite multiple requests.
Failure to Provide Timely ADL Assistance and Restorative Care
Penalty
Summary
Two residents did not receive appropriate assistance with activities of daily living (ADLs) to maintain their highest practicable physical well-being. One resident, who had a perirectal abscess with a large residual wound following surgery, experienced delays in receiving timely toileting and incontinence care. This resident reported multiple instances where staff did not respond promptly to call lights, resulting in prolonged periods of sitting in urine or stool. Documentation and interviews revealed that staff sometimes failed to properly clean the resident after incontinence episodes, and on at least one occasion, a staff member declined to provide care, leaving the resident soiled until seen by outside wound clinic staff. The resident expressed discomfort, embarrassment, and concern that inadequate care could affect wound healing. Facility staff, including the Director of Nursing and Social Worker, were not consistently aware of these incidents or the related wound clinic notes. Another resident, with diagnoses including diabetes with polyneuropathy and repeated falls, was discharged from physical therapy with a recommendation for a restorative ambulation program. The program specified ambulation in the hallway once per shift with caregiver assistance. However, the resident's care plan did not include this ambulation or a restorative program, and staff were unaware of the walking schedule. Documentation showed that the resident was not consistently ambulated as recommended, with the majority of opportunities for ambulation marked as 'not applicable,' indicating the task did not occur. The resident expressed a desire to walk in the hallway with staff and reported not walking much since therapy ended. Facility policies required staff to provide timely responses to call lights, maintain residents' ADL abilities, and implement restorative nursing programs as indicated by assessments and therapy recommendations. In both cases, the facility failed to follow its own policies and procedures, resulting in residents not receiving necessary care and services to maintain their physical functioning and dignity.
Failure to Investigate Falls and Update Care Plans After Multiple Incidents
Penalty
Summary
Surveyors identified that the facility failed to ensure areas were free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents with a history of falls and cognitive impairment. Three residents with moderate cognitive impairment and significant medical conditions, including dementia, encephalopathy, osteoarthritis, diabetes, and hemiplegia, experienced multiple unwitnessed falls. Despite these incidents, the facility did not conduct thorough fall investigations to identify root causes or update the residents' care plans with new interventions to prevent further falls. The review of medical records revealed that after each fall, the facility did not consistently complete required neurological checks as outlined in their Fall Checklist. For several falls, neuro checks were missing or incomplete, and in some cases, the checks were performed at incorrect intervals. Additionally, the facility lacked a formal falls policy and relied on an undated Fall Checklist, which was not consistently followed by staff. The Director of Nursing confirmed that fall investigations did not identify root causes, care plans were not updated, and neuro checks were not thoroughly completed following unwitnessed falls. For one resident, five falls occurred over a two-week period without any new safety interventions being added to the care plan. Another resident experienced six falls, including incidents resulting in injury and hospital transfer, yet no new interventions were implemented, and one fall was not investigated at all. The facility's failure to follow fall procedures, update care plans, and complete post-fall assessments contributed to the deficiency identified by surveyors.
Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control program based on direct observations, staff interviews, and record reviews involving two residents. One resident with a Foley catheter and multiple diagnoses, including Parkinson's disease and urinary retention, received perineal care from two CNAs who failed to perform hand hygiene between glove changes. The CNAs changed gloves multiple times during care, touched various clean and contaminated surfaces, and only performed hand hygiene after leaving the resident's room, contrary to facility policy. Another resident with a PEG tube and Parkinson's disease received pericare from an LPN who did not wash hands before donning gloves and did not wear a gown, despite the resident's use of an indwelling medical device. There was also no Enhanced Barrier Precautions (EBP) signage or PPE cart outside the resident's room, as required by facility policy. The LPN stated a misunderstanding of when gown use was necessary, believing it was only required if the resident was sick. Facility policies reviewed by surveyors clearly outlined the need for hand hygiene before and after glove use, the use of gowns and gloves during high-contact care activities for residents with indwelling devices, and the posting of EBP signage and availability of PPE. Both direct care staff and the Director of Nursing confirmed during interviews that the observed practices did not align with facility policies and procedures.
Failure to Complete Ordered Wound Care
Penalty
Summary
The facility failed to ensure wound care was completed as ordered for two residents, leading to a finding of immediate jeopardy. Resident 1, admitted for rehabilitation following surgery for Charcot's foot, had a physician's order for daily dressing changes. However, these dressing changes were not completed from May 22 to May 27, resulting in the discovery of maggots in the surgical wound by a registered nurse. The resident was subsequently transferred to the hospital for wound debridement and treatment with intravenous antibiotics. Resident 4 also experienced a lapse in wound care. The resident had a treatment order for a chronic ulcer on the right heel and midfoot, which required dressing changes three times a week. On June 14, the dressing change was not completed as ordered, and there was no documentation to indicate the treatment was performed. The Director of Nursing confirmed the missed treatment, and a subsequent dressing change revealed the previous dressing had not been changed since June 12. The facility's failure to adhere to the prescribed wound care regimen for these residents resulted in significant harm for Resident 1 and potential harm for Resident 4. The lack of documentation and follow-through on ordered treatments contributed to the deficiencies identified by the surveyors.
Removal Plan
- Initiated staff-wide education regarding wound care, neglect, TAR/Medication Administration Record (MAR) sign-outs, and resources.
- Initiated ongoing review with staff during huddles.
- Reviewed all current residents with wounds to ensure dressings were changed as ordered.
- Initiated a plan to complete dressing change audits to ensure all dressings are changed as ordered.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility did not ensure food was stored and prepared in a sanitary manner, potentially affecting all 24 residents. During an initial kitchen tour, it was observed that the kitchen cooler contained items such as beef tips, cream of soup, and turkey soup that were not listed on the cooling log. The Dietary Manager confirmed that the facility's process is to document food cooling temperatures on the cooling log to ensure food is cooled safely with an approved cooling method. However, the leftover items in the cooler were stored without following the facility's cooling policy, which is a violation of the Wisconsin Food Code 2022 regarding cooling methods and time/temperature control for safety food. Additionally, the cleanliness of the kitchenettes was found to be inadequate. During a tour of the [NAME] Garden Home kitchenette, it was noted that the toaster contained crumbs, the refrigerator had multiple brown and white smudged food particles on the outside doors and handles, and the inside door of the vegetable crisper contained brown food particles, dried lettuce leaves, and onion skins. The bottom of the refrigerator and the bottom drawer of the freezer also contained various stains, discarded twist ties, and food particles. These unsanitary conditions were observed on two separate days, and the Dietary Manager confirmed that the kitchenettes should be cleaned daily and as needed by staff, which was not being done.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility did not ensure the resident environment for one resident was as free of accident hazards as possible. The facility failed to implement fall interventions contained in the resident's person-centered comprehensive care plan and medical record. The resident, who had severe cognitive impairment and multiple diagnoses including chronic diastolic heart failure and type 2 diabetes, experienced several falls resulting in injuries. Despite the care plan specifying interventions such as keeping the bed in the lowest position and placing a floor mat next to the bed, these measures were not consistently followed. Observations by the surveyor revealed the bed was not in the lowest position and the floor mat was not in place on multiple occasions. The resident's medical record indicated a history of falls, including incidents where the resident slid out of a wheelchair, fell from a recliner, and fell from bed, resulting in injuries such as a fractured left arm and femur. The Director of Nursing confirmed the interventions were required and acknowledged the failure to implement them. The lack of adherence to the care plan interventions contributed to the resident's repeated falls and injuries, highlighting a significant deficiency in ensuring a safe environment for the resident.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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