Edenbrook Lakeside
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukee, Wisconsin.
- Location
- 2115 E Woodstock Pl, Milwaukee, Wisconsin 53202
- CMS Provider Number
- 525319
- Inspections on file
- 32
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Edenbrook Lakeside during CMS and state inspections, most recent first.
The facility failed to consistently designate a licensed nurse as charge nurse on each shift and did not staff according to its own facility assessment and stated minimum ratios, especially on weekends. Nursing schedules reviewed over a 30‑day period did not clearly identify a charge nurse for every tour of duty, and leadership acknowledged reliance on informal knowledge and an on‑call rotation rather than documented assignment. The facility assessment outlined higher nurse and CNA staffing levels by floor and shift, based on census and acuity, than those actually scheduled, and surveyor review showed reduced weekend staffing over several months, contributing to a pattern of excessively low weekend staffing affecting all residents.
A respiratory therapist with an expired and non-renewed license continued to work in a respiratory therapist capacity, monitoring and providing care for an average of 14 residents with tracheostomies. The facility lacked a credentialing policy for respiratory therapists, and responsibility for tracking licenses had been assigned to a former HR manager. The NHA was unaware of the license lapse until shortly before the survey, while the SDD reported using tracking tools but confirmed that the departed HR manager had been responsible for monitoring this therapist’s license status.
A resident with multiple medical conditions and an identified ADL self-care deficit was care planned to receive one-person assistance with bathing, dressing, and personal hygiene, with showers scheduled twice weekly. Over several days, the resident was observed with disheveled, later matted, hair and wearing the same clothing, while review of records showed no showers provided since admission and no documentation of any refusals in the EMR, despite facility policy requiring documentation and re-approach of refusals. Staff interviews revealed uncertainty about whether the resident had refused showers and an ADON assertion that the resident should have bathed at home during a pass, while the resident reported not having time to shower at home and expressed a desire for a shower, demonstrating that necessary ADL services for bathing and grooming were not provided or documented as required.
A resident was transferred to the hospital without being provided all required transfer notice information, including the reason for transfer, appeal rights, and correct Ombudsman contact details. The forms used by the facility, created and revised by the corporate office, did not meet regulatory requirements, and staff confirmed the missing information.
A resident was denied immediate readmission after hospitalization because facility staff required additional insurance paperwork, despite the resident's Medicaid coverage and no change in clinical status. Miscommunication among staff led to the resident being sent back to the hospital, even though there was no regulatory reason to deny readmission.
A resident with severe cognitive impairment and multiple medical conditions did not receive post-fall assessments as required by the facility's policy. The policy mandates documentation every shift for 72 hours post-fall, but assessments were missing for several shifts following two separate falls. The Director of Nursing confirmed the deficiency during an interview.
A facility failed to maintain ongoing communication with a dialysis center for a resident requiring dialysis, resulting in a lack of documented communication for 12 appointments. The facility's policy mandates reviewing post-dialysis communication, which was not followed. The issue was attributed to the dialysis center not returning the communication binder, and attempts to retrieve information via fax were made. The deficiency was noted by a surveyor and communicated to the facility's administration.
Two residents in the facility did not have comprehensive care plans addressing their specific needs. One resident with a foley catheter lacked a care plan for catheter management, while another resident's care plan inaccurately documented toileting needs despite frequent incontinence. The facility's failure to update care plans reflects a lapse in the interdisciplinary team process and communication.
A resident receiving medications through a G tube did not receive care meeting professional standards when an LPN administered medications without verifying tube placement. The facility's policy requires checking the tube's placement before administering medications, but this procedure was not followed. The Director of Nursing acknowledged the concern, confirming the policy requirement.
A facility's medication error rate was 41.67% due to an LPN failing to flush a resident's G tube with water before and after administering 15 medications, contrary to the facility's policy. The DON acknowledged the policy violation.
A resident with multiple diagnoses did not receive several physician-ordered medications upon admission due to unavailability, and the physician was not notified. The DON confirmed the lapse, which was against facility policy.
A resident did not receive insulin before meals as ordered by the physician. The insulin was administered after meals on multiple occasions, contrary to the facility's policy and the physician's orders. The RN delayed the administration due to concerns about the resident not eating and other issues on the floor. The DON confirmed the discrepancy.
Failure to Designate Charge Nurses and Maintain Weekend Staffing per Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff and to designate a licensed nurse as charge nurse for each tour of duty, as required to meet residents’ needs. Review of 30 days of nursing schedules showed that the schedules did not consistently identify who the charge nurse was for each shift, and sometimes listed a charge nurse only for the evening shift. During an interview, the Staff Development Director stated that during the day the DON, assistant DONs, or infection preventionist are in the building and that staff "know" who the evening and night charge nurses are, and referenced an on‑call rotation. However, the facility did not provide documentation or explanation showing that a licensed charge nurse was clearly designated on each shift, and the Nursing Home Administrator acknowledged the concern when interviewed about the schedules. The deficiency also includes the facility’s failure to staff according to its own facility assessment and stated minimum staffing ratios, particularly on weekends. The facility assessment, last reviewed in November 2025, specified licensed nurse‑to‑resident and CNA‑to‑resident ratios and detailed expected staffing by floor and shift, with staffing to be based on census and acuity. In contrast, the Staff Development Director described lower minimum staffing levels actually used on the schedule, and surveyor review of October 2025 schedules showed reduced staffing on weekends compared to both the facility assessment and the Director’s stated minimum ratios. The facility triggered for excessively low weekend staffing from October through December 2025, and both the Staff Development Director and the Nursing Home Administrator acknowledged staffing challenges during that period, with no additional information provided to reconcile the discrepancy between assessed needs and actual staffing. This deficient practice had the potential to affect all 98 residents in the facility.
Unlicensed Respiratory Therapist Provided Tracheostomy Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that specialized respiratory therapy services were provided by qualified, licensed personnel. The facility had an average of 10–18 residents receiving tracheostomy care, with an average census of 14 residents with tracheostomies while Respiratory Therapist (RT)-L was employed. RT-L was hired with a respiratory therapist license that later expired, and RT-L continued to work in a respiratory therapist capacity in the facility after the license expiration date. Review of the Department of Human Services (DHS) online license look-up confirmed that RT-L’s license had expired and that renewal had been denied. Time clock records verified that RT-L continued to work in the role of a respiratory therapist after the license expiration and up until the last recorded work date. The facility did not have a policy for credentialing respiratory therapists, and responsibility for monitoring licenses had been assigned to a human resources manager who was no longer employed at the facility. The Nursing Home Administrator (NHA) reported being unaware that RT-L’s license had lapsed until informed shortly before the survey and acknowledged concern about the situation. The Staff Development Director (SDD) described using a checklist and spreadsheet to track employee licenses and certifications but indicated that the former human resources manager was responsible for monitoring RT-L’s license status. Another respiratory therapist (RT-N) stated that respiratory therapists in the facility are primarily responsible for monitoring all residents with tracheostomies, confirming that RT-L was functioning in this capacity while unlicensed.
Failure to Provide and Document Assisted Bathing and Hygiene for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, specifically bathing, grooming, and personal hygiene, to a resident who required assistance. Facility policy on ADLs, revised 2/25/2025, states that residents will receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including assistance with bathing/showering, personal hygiene, and dressing, individualized to resident needs and preferences, with refusals reported to a nurse, re-approached, and documented in the EMR. The resident’s comprehensive care plan dated 3/18/26 identified an ADL self-care performance deficit related to multiple medical conditions, with interventions specifying one-person assist for bathing/showering, dressing, and personal hygiene/oral care, and assistance with clothing selection and dressing. Despite these care plan directives, the resident was repeatedly observed over multiple days with very disheveled hair and wearing the same long sleeve blue shirt and dark gray pants, with hair later noted to be matted in some areas. The CNA assignment book showed the resident was scheduled for showers twice weekly, yet review of shower documentation revealed the resident had not received any showers since admission. The resident reported possibly having had only one shower since admission, was aware that their hair was “wild,” and stated they did not have other clothes to change into. There was no documentation in the EMR of any shower refusals by the resident. Interviews with staff further demonstrated a lack of adherence to policy and care plan. One CNA described the process for re-approaching residents who refuse showers but did not confirm refusals for this resident, stating they had not worked or been assigned to the resident on shower days. The ADON initially stated the resident had refused all showers and that such refusals should be documented in the EMR, but upon review with the surveyor, acknowledged there was no documentation of refusals. The ADON also stated that the resident should have taken a shower at home during a pass, and later questioned the resident, who reported not having time to shower at home and expressed a desire for a shower. These observations and interviews show that the resident did not receive the planned and required assistance with bathing, grooming, and personal hygiene, and that staff did not document any refusals as required by facility policy.
Failure to Provide Complete Transfer Notice Information
Penalty
Summary
The facility failed to provide all required transfer notice information for a resident who was transferred to the hospital. Specifically, the documentation for the resident's transfer did not include the reason for the transfer, information about appeal rights, the correct contact information for the Ombudsman, or the correct email address for the Regional Field Operations Director for the Division of Quality Assurance. The facility's policy requires that residents and their representatives receive written notice of transfer or discharge, including specific information about the transfer, appeal rights, and contact details for relevant advocacy entities. Review of the resident's medical record showed that the Bed-Hold Agreement - Transfer Notice forms used on two separate occasions were missing required elements. Interviews with facility staff revealed that the forms were created and revised by the corporate office, but even the most recent versions did not meet regulatory requirements. The staff responsible for maintaining these forms confirmed that the necessary information was not included in the documents provided to the resident and their representative.
Resident Denied Readmission Due to Administrative Paperwork Delay
Penalty
Summary
The facility failed to permit a resident to return to the facility immediately following hospitalization, despite there being no clinical or regulatory reason to deny readmission. The resident, who was covered by a managed Medicaid plan and had a legal guardian, was transferred to the hospital and, upon discharge, was ready to return to the facility. The facility's own policy states that a resident whose hospitalization exceeds the bed-hold period should be readmitted if they require the facility's services and are eligible for Medicaid or Medicare. However, when the hospital attempted to discharge the resident back to the facility, the facility refused readmission, citing incomplete insurance paperwork, specifically the absence of a Medicare denial form, even though the resident's Medicaid plan would continue to cover the stay and such a denial was not required. Interviews with facility staff revealed confusion and miscommunication regarding the necessary paperwork for readmission. The Director of Marketing confirmed that all authorizations were believed to be in place, but the Corporate Admissions staff insisted on having a Medicare denial form before readmitting the resident. The Nursing Home Administrator acknowledged misunderstanding the situation and did not allow the resident to return, resulting in the resident being sent back to the hospital. The surveyor confirmed there was no regulatory reason for the denial, and the facility's actions were based solely on internal administrative requirements rather than the resident's clinical status or eligibility.
Failure to Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that a resident received post-fall assessments as per the facility's policy, which requires documentation of the resident's condition every shift for 72 hours following a fall. This deficiency was identified for one resident who experienced falls on two separate occasions. The facility's policy mandates that staff document relevant clinical findings such as vital signs, pain, swelling, bruising, and changes in function or cognitive status after a fall. However, the surveyor found that for the falls occurring on June 29 and August 30, several shifts lacked the required assessments, with five shifts missing documentation for each fall. The resident involved had a history of significant medical conditions, including nontraumatic intracerebral hemorrhage, hydrocephalus, encephalopathy, abnormalities of gait and mobility, cognitive communication deficit, and restless leg syndrome. The resident was also noted to be severely cognitively impaired with impairments to one side of their upper and lower extremities. Despite these conditions, the facility did not complete the necessary post-fall assessments, as confirmed by the Director of Nursing during an interview. The Director acknowledged that the assessments should have been completed as scheduled but admitted that the documentation provided to the surveyor was all that was available.
Failure in Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with a dialysis center for a resident requiring dialysis services, as per professional standards of practice. The resident, who is cognitively intact and has a physician order for dialysis three times a week, had no communication documented between the facility and the dialysis center for 12 scheduled dialysis appointments. The last recorded communication was dated over a month prior to the surveyor's review. The facility's policy requires reviewing communication documents for pertinent information post-dialysis, which was not adhered to in this case. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the issue, attributing it to the dialysis center's failure to return the communication binder. Despite attempts to retrieve the missing information via fax, the facility struggled to maintain up-to-date records. The surveyor highlighted the importance of timely communication as per the Center for Medicare/Medicaid Services memorandum, which emphasizes the need for collaboration between dialysis facilities and nursing homes to ensure effective and safe treatments. The deficiency was communicated to the DON and Nursing Home Administrator during an end-of-day meeting.
Deficiencies in Comprehensive Care Planning for Two Residents
Penalty
Summary
The facility failed to ensure that two residents, R82 and R31, had individualized comprehensive care plans addressing their specific needs. R82, who was admitted with multiple diagnoses including a fracture, Guillain-Barre syndrome, and diabetes, had a foley catheter inserted due to urinary retention. Despite this significant change in R82's condition, the facility did not develop a comprehensive care plan for the catheter management, as confirmed by the surveyor's review of R82's records and interviews with the Director of Nursing (DON). The DON acknowledged that the care plan should have been initiated when the catheter was inserted, but it was missed in the daily morning meetings where care plans are typically finalized. R31, another resident with diagnoses including metabolic encephalopathy and muscle weakness, was assessed as frequently incontinent of bowel and bladder. However, the care plan in place was not person-centered or comprehensive, as it inaccurately stated that R31 was not toileted, despite the resident's MDS indicating frequent incontinence. The surveyor's interview with R31 revealed that the resident received assistance when needed, contradicting the care plan's documentation. The DON initially believed the care plan was resolved because R31 was thought to be continent, but upon review, it was acknowledged that the care plan was incorrectly resolved. These deficiencies highlight the facility's failure to adhere to its policy of developing individualized, comprehensive care plans based on residents' assessments and needs. The lack of appropriate care plans for R82's catheter management and R31's incontinence care indicates a lapse in the facility's interdisciplinary team process and communication, as care plans were not updated or initiated in response to changes in the residents' conditions.
Failure to Verify G Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident receiving medications through a gastronomy (G) tube received care that met professional standards. On October 24, 2024, a surveyor observed a Licensed Practical Nurse (LPN) administering medications to a resident via a G tube without verifying the tube's placement beforehand. The facility's policy, revised on September 8, 2023, requires that the placement of the feeding tube be verified before administering medications, which includes checking the tube's external length and inspecting gastric aspirate. However, the LPN did not follow this procedure and proceeded to administer 15 crushed medications mixed with water without checking the tube's placement. The resident in question had a physician's order dated March 17, 2023, which mandated that the tube placement be checked before the initiation of formula, medication administration, and flushing, or at least every eight hours. During an interview with the Director of Nursing (DON), the surveyor explained the concern regarding the LPN's failure to check the G tube placement. The DON acknowledged the concern and confirmed that it is the facility's policy to verify tube placement prior to medication administration. No additional information was provided by the facility regarding this incident.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to ensure its medication error rates were not 5 percent or greater, resulting in a medication error rate of 41.67%. On October 24, 2024, a resident identified as R55 was administered 15 medications via a gastronomy (G) tube by an LPN. The LPN did not flush the G tube with water before or after administering the medications, which is a violation of the facility's policy. The facility's policy, revised on September 8, 2023, requires flushing the tube with 30 ml of water before and after medication administration. The physician's order allowed for combining medications during G tube administration with flushes as ordered. The Director of Nursing acknowledged the concern when interviewed by the surveyor, confirming that the facility's policy was not followed.
Failure to Administer Ordered Medications Upon Admission
Penalty
Summary
The facility failed to ensure that a resident received ordered medications upon admission, leading to unmet care and health needs. The resident, who had diagnoses including the presence of a right artificial knee joint, end-stage renal disease, and kidney transplant status, was admitted to the facility in the evening. However, several physician-ordered medications were not administered due to unavailability, and there was no evidence that the physician was notified about the unavailability of these medications. Specifically, Belsomra, Prednisone, Apixaban, and Calcium Acetate were not given as ordered on the evening of admission and the following day. The Director of Nursing (DON) confirmed that the medications were not administered and that there were no progress notes indicating that the physician was notified. Facility policy requires that medications be administered according to physician orders and that the physician be notified if medications are not available or not given. The failure to administer these medications and notify the physician was verified through record reviews, interviews, and facility policy review.
Failure to Administer Insulin Before Meals
Penalty
Summary
The facility failed to administer insulin to one resident in a timely manner, as per the physician's order. The resident's Medication Administration Record (MAR) indicated that insulin was to be administered before meals based on a sliding scale determined by the resident's blood sugar levels. However, the insulin was administered after meals on multiple occasions. The resident reported receiving her insulin injections late, both in the morning and at noon, which was confirmed by the Registered Nurse (RN) who administered the insulin. The RN admitted to delaying the insulin administration due to concerns about the resident not eating and other issues on the floor. The Director of Nursing (DON) confirmed that the insulin was administered after meals, contrary to the physician's orders. The facility's policy on administering medications, which requires adherence to the physician's written orders, was not followed. This failure to administer insulin before meals as ordered had the potential to result in unmet healthcare needs 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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
