Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Madison during CMS and state inspections, most recent first.
The facility failed to notify the responsible party timely when a resident developed a new deep tissue injury (DTI). Despite the resident's high risk for skin breakdown and the facility's policy requiring immediate notification, the charge nurse did not document or recall notifying the family. The Director of Nursing confirmed the necessity of such notifications but could not provide evidence that it was done.
A facility failed to maintain complete and accurate medical records for a resident receiving end-of-life care. The records lacked documentation of ADL care, hospice services, and the assessment at the time of death due to a change in ownership and missing records from the prior owner.
The facility failed to prevent and treat pressure ulcers for two residents. One resident developed an unstageable pressure ulcer due to inadequate repositioning and off-loading, while another resident's new pressure ulcer was not properly assessed or treated. Staff did not adhere to policies, and documentation was inconsistent.
The facility failed to adequately staff NAs, resulting in unmet care needs for residents. One resident with dementia was observed with poor hygiene due to insufficient staffing. Another resident with Alzheimer's had long, dirty nails, and a third resident with Down Syndrome was inadequately supervised, leading to unsafe behavior. Staff interviews and facility records confirmed frequent understaffing and restricted use of agency staff.
The facility failed to provide adequate snacks for residents during a 15-hour gap between dinner and breakfast. Snacks were only given upon request and were insufficient, with some units not receiving snack carts for weeks, contrary to facility policy.
The facility failed to follow infection control practices, leaving a resident's room in disarray and lacking required policies for undiagnosed respiratory illness and early detection of potentially infectious residents. This indicates significant gaps in the facility's infection control program.
The facility failed to adequately respond to resident grievances, including early supper meal times, lack of alternative meal choices, and staff discussing personal information loudly. Despite being aware of these issues, the facility did not take effective action to resolve them.
The facility failed to maintain a clean, comfortable, and homelike environment. Observations revealed trash on floors, deteriorated window seats, and broken wood molding in resident rooms. Interviews indicated that maintenance relied on staff notifications for repairs and did not perform routine audits. The facility also lacked an environmental condition and/or repair policy.
The facility failed to provide adequate personal hygiene care to several residents, resulting in long, soiled fingernails and unshaven facial hair. Staff cited staffing shortages and dull razors as reasons for the neglect, and nursing notes did not document any refusal of care by the residents.
The facility failed to label oxygen tubing for residents requiring oxygen therapy, despite physician orders. Multiple residents with conditions such as COPD, anoxic brain damage, and dementia were observed with unlabeled oxygen tubing. Staff confirmed the tubing was not labeled and did not routinely change it as required.
The facility failed to complete annual performance appraisals for two nurse aides. One aide's last appraisal was not dated, and another's was five years old. The Administrator cited inconsistent staffing and multiple changes in the DNS position as reasons for the lapse. Facility policy mandates annual appraisals and in-service education based on these reviews.
The facility failed to ensure behavior monitoring for two residents receiving psychotropic medications. One resident with dementia and agitation was prescribed Risperidone, and another with Down Syndrome and Alzheimer's was prescribed Olanzapine. In both cases, there was no documented behavior monitoring, contrary to facility policy.
The facility failed to provide dental services for a resident with significant medical conditions, despite multiple evaluations indicating the need for a dental consult. The resident had not seen a dentist since admission over a year and eight months ago, and the required permission forms were not completed by the admitting nurse.
The facility failed to ensure safe water temperatures in resident areas, with multiple instances of bathroom sink water temperatures exceeding the safe limit of 120 degrees Fahrenheit. The Director of Maintenance did not follow the facility's policy for monitoring and adjusting water temperatures and failed to notify the Administrator of the excessive temperatures.
The facility failed to ensure that two nurse aides completed the mandatory 12 hours of in-service education annually, including dementia care training. The training records were incomplete, and the facility could not provide an annual in-service training policy.
A resident with a suprapubic catheter was observed in the dining area with an exposed urinary collection bag. The OT assisting the resident was unaware of the need for a privacy cover, and the DNS confirmed the policy but could not provide a written document.
The facility failed to ensure accurate documentation and updating of advance directives for three residents. Discrepancies were found in the code status of one resident, while two others lacked documented advance directives upon admission. Staff interviews revealed confusion and lack of clarity regarding responsibilities for updating records.
A resident with dementia and other health issues experienced significant weight loss over three months. The facility failed to notify the resident's representative, and the dietician confirmed the lack of a specific policy for such notifications, highlighting a systemic communication issue.
A resident with Down Syndrome and Alzheimer's was found restrained to their wheelchair with a bed sheet due to insufficient staffing and inadequate supervision. The restraint was discovered by an SLP, who reported the incident, revealing ongoing staffing issues and inadequate behavioral interventions in the care plan.
A resident with multiple diagnoses, including Down Syndrome and Alzheimer's, was found restrained to a wheelchair by a bed sheet. The incident, admitted by a nursing assistant, was not reported to managerial staff until three days later, and the Administrator delayed reporting to the state agency, citing a lack of information from a witness. This delay violated the facility's abuse reporting policy.
The facility failed to update and implement new interventions in the care plans for several residents following significant events, including falls and the development of pressure ulcers. Care plans were not revised to reflect increased needs or to prevent further incidents, leading to inadequate care and safety measures.
The facility failed to provide appropriate foot care for a resident with chronic kidney disease, total hip arthroplasty, and gout. Despite a physician's order to consult podiatry as needed and multiple requests for foot care, no referral was made. Observations revealed the resident's toenails were long and curling forward, and the facility's Foot Care policy was not followed.
The facility failed to implement care plan interventions, provide adequate supervision, and conduct risk assessments following falls for three residents. Despite being identified as fall risks, the residents experienced unwitnessed falls due to inadequate monitoring and non-compliance with fall protocols.
The facility failed to notify the Ombudsman regarding multiple hospital transfers of a resident with heart failure, anemia, and dementia. Despite several medical emergencies requiring hospital transfers, the facility did not follow its policy for timely notification, as confirmed by interviews with the Social Worker and the Ombudsman.
The facility failed to notify a resident's representative in writing about the bed hold policy during multiple hospital transfers, despite the resident's moderate cognitive impairment and need for assistance. The Business Office Manager acknowledged the oversight, noting a recent shift in responsibility for completing the notifications.
Failure to Notify Responsible Party of Change in Skin Integrity
Penalty
Summary
The facility failed to ensure the responsible party was notified timely when a change in skin integrity was identified for Resident #1. Resident #1, who was admitted with diagnoses including schizoaffective disorder, generalized muscle weakness, and senile degeneration of the brain, was at risk for skin breakdown due to inadequate oral intake, fragile skin, incontinence, and limited mobility. Despite interventions such as floating heels while in bed and using a low-loss mattress, a deep tissue injury (DTI) was identified on Resident #1's right foot by a wound Nurse Practitioner (NP) on 10/23/2023. However, the clinical record review failed to show that the responsible party was notified of this new DTI. Interviews with the infection control/wound nurse and the charge nurse revealed that the charge nurse was responsible for notifying the family and documenting the notification in the clinical record. The charge nurse on duty at the time of the DTI identification could not recall if the family was notified and acknowledged that if it was not documented, it was not done. The Director of Nursing (DON) confirmed that notification to the physician and family was necessary for new pressure areas but was unable to provide documentation that the family was notified. The facility's policy on Change in Condition: Notification of, dated 6/1/2021, directed that the facility must immediately inform the resident's health care authority or Health Care Decision Maker of significant changes in the resident's physical status or the need to commence new treatment.
Incomplete Medical Records and Documentation for End-of-Life Care
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was receiving end-of-life care. The resident, who had diagnoses including schizoaffective disorder, generalized muscle weakness, and senile degeneration of the brain, was at risk for skin breakdown and had a Stage III pressure ulcer. However, the facility did not have documentation of Activities of Daily Living (ADL) care for a specific period due to a change in ownership, and the requested documentation from the prior owners was not available for review. This lack of documentation was against the facility's ADL policy, which required real-time recording of ADL care in the medical record. Additionally, the resident was on hospice services, but the medical record lacked the hospice election form and documentation of hospice services provided during a specific month. The facility's hospice policy required obtaining the hospice election form and documenting all hospice care provided. The Director of Nursing (DON) acknowledged the missing documentation and indicated that a request had been made to the prior owner's corporate office and the hospice service provider to obtain the necessary records. Furthermore, the facility failed to document the assessment of the resident at the time of death. Although a registered nurse (RN) pronounced the resident's death and notified the family, the RN did not document the assessment criteria used to determine death, as required by the facility's Pronouncement of Death policy. The policy mandated detailed documentation of the clinical criteria for pronouncing death, including vital signs, pupil reaction, and other physical assessments. The DON confirmed that the facility did not have access to the prior owner's electronic medical records and had requested the missing documentation.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of pressure ulcers and provide necessary treatment for two residents. For Resident #9, the facility did not ensure timely turning, repositioning, and off-loading of heels, failed to conduct pressure ulcer risk assessments per policy, and did not perform weekly skin assessments. Despite Resident #9's decline in condition due to pneumonia and urinary tract infection, the care plan was not updated to reflect the increased need for assistance. This led to the development of an unstageable pressure ulcer on the left heel, which worsened over time due to inadequate off-loading and repositioning by staff. For Resident #62, the facility failed to conduct an initial pressure ulcer assessment, obtain initial measurements, inform the wound nurse of the new pressure ulcer, and ensure off-loading of the pressure area. Despite a physician's order for heel boots at all times, Resident #62 was observed without heel boots on multiple occasions. The facility's documentation did not reflect the presence of a new pressure ulcer, and the wound nurse was not informed, leading to a lack of appropriate treatment and monitoring. Interviews with staff revealed a lack of adherence to the facility's policies and procedures for pressure ulcer prevention and care. Staff failed to implement new interventions when residents' conditions changed, did not conduct required assessments, and did not ensure proper off-loading of pressure areas. The facility's documentation was inconsistent and did not accurately reflect the residents' needs or the care provided, contributing to the development and worsening of pressure ulcers in both residents.
Inadequate Staffing Leads to Unmet Resident Care Needs
Penalty
Summary
The facility failed to adequately staff Nurse Aides (NAs) throughout the facility, resulting in unmet resident care needs. Resident #21, diagnosed with dementia and heart disease, was observed with long, dirty fingernails and unshaven facial hair, indicating a lack of personal hygiene care. Despite requiring extensive assistance, the resident's hygiene needs were not met due to insufficient staffing, as confirmed by NA #2, who stated that hygiene tasks were often neglected when the facility was understaffed. The facility's documentation and interviews revealed that the required number of staff was rarely met, leading to compromised care for residents like Resident #21. Resident #53, diagnosed with Alzheimer's disease and major depressive disorder, was also observed with long, jagged nails and dried blood on their hands. Despite the care plan indicating the need for extensive assistance with personal hygiene, the resident's nails remained untrimmed and dirty. Interviews with NAs revealed that nail care and other hygiene tasks were only completed when the facility was fully staffed, which was not often the case. The NAs reported having assignments of up to 12 residents when short-staffed, making it difficult to provide adequate care. Resident #527, diagnosed with Down Syndrome and Alzheimer's Disease, exhibited behaviors such as disrobing and attempting to self-transfer, requiring close supervision. However, due to staffing shortages, the resident was not adequately monitored, leading to incidents of self-harm and unsafe behavior. On one occasion, an NA resorted to restraining the resident with a bed sheet due to the inability to provide proper supervision. Interviews with staff and review of facility records confirmed that the unit was frequently understaffed, with managerial staff acknowledging the lack of sufficient personnel to meet the residents' needs. The facility's corporate policies further restricted the use of agency staff, exacerbating the staffing issues and compromising resident care.
Inadequate Snack Provision for Residents
Penalty
Summary
The facility failed to provide adequate snacks for residents when mealtimes exceeded 14 hours. Observations and interviews with residents revealed that snacks were only provided upon request and consisted of small items such as cookies, cookie bars, applesauce, or juice, which residents did not consider adequate or substantive. The meal schedule showed a 15-hour gap between dinner at 4:30 PM and breakfast at 7:30 AM, during which residents were not provided with sufficient nourishment. Interviews with dietary staff and nursing aides indicated inconsistencies in the delivery of snack carts to the units, with some units not receiving snack carts for weeks at a time. The facility's policy stated that evening snacks should be planned as part of the menu and that stock foods should be stored for use on nursing units. However, observations and staff interviews confirmed that this policy was not being followed, leading to residents not receiving the necessary nourishment during long gaps between meals.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow infection control practices on one of its units, specifically in the case of Resident #53. Resident #53, who has Alzheimer's disease, cognitive communication deficit, and inflammatory polyarthropathy, was observed in a room with a full trash can on the bedside chair and soiled linens and incontinent pads on the floor. The resident's care plan indicated they required extensive assistance with activities of daily living, including bed mobility, dressing, personal hygiene, and bathing. A housekeeper confirmed that the room should not have been left in such a state and suggested that staff often leave rooms messy, making it difficult for her to maintain cleanliness given her workload of 40 rooms per shift. This indicates a lapse in maintaining a clean environment for the resident, which is crucial for infection control. Additionally, the facility's infection control program was found lacking required policies for undiagnosed respiratory illness and a plan for early detection and management of potentially infectious residents. During an interview, a registered nurse was unable to locate these policies or provide guidance on them, and neither she nor the Director of Nursing Services could find the missing policies. The facility's Infection Control Outcome and Process Surveillance and Reporting policy, last revised on 2/1/23, mandates regular surveillance and compliance monitoring, but the absence of these critical policies indicates a significant gap in the facility's infection control program.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately respond to resident grievances as identified in the Resident Council meeting minutes. Residents expressed concerns about the early arrival of supper meals and the lack of alternative meal choices. Despite these concerns being documented and communicated to the dietary staff, the issue persisted. Additionally, residents reported that they were left in bed until lunch due to staffing shortages, and their beds were not made or changed after they got up. Staff were also heard discussing personal information loudly in the hallways and using inappropriate language. These issues were raised multiple times in Resident Council meetings, but the facility did not take effective action to resolve them. Interviews with the Director of Dietary and the Director of Nursing Services (DNS) revealed awareness of the issues but highlighted systemic problems such as the lack of a Human Resources staff member and restrictions on using agency staff due to cost. The DNS admitted that the facility was aware of the staffing issues but had not been informed about the specific concern regarding the early arrival of dinner. The Director of Dietary acknowledged the problem but indicated that it persisted when a manager was not present. The facility's grievance policy mandates prompt investigation and resolution of concerns, which was not adequately followed in this case.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure equipment and furniture were maintained in a clean, comfortable, and homelike manner. During an initial facility tour, trash was observed on the floors in the hallways and in several resident rooms. In one room, a medicine cup with white powder was found on the floor, and used medical gloves were seen in flower boxes. Additionally, a piece of wood molding under a window seat was broken, exposing a sharp edge. Multiple rooms had window seats that were significantly deteriorated, with cracked, peeling, and discolored padding, and worn wood cabinets with no protective finish. Interviews with the Director of Maintenance and the Maintenance Assistant revealed that maintenance was responsible for maintaining the furnishings but relied on staff to notify them of needed repairs. The Director of Maintenance was unaware of the disrepair in certain rooms and indicated that routine audits or rounds to observe room conditions were not performed. The facility also failed to provide an environmental condition and/or repair policy when requested.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to ensure personal hygiene care and services were provided to dependent residents, as evidenced by observations and interviews. Resident #21, diagnosed with dementia and heart disease, was observed with dark debris under fingernails and long facial hair on multiple occasions. Despite being identified as requiring assistance with personal hygiene, staff interviews revealed that hygiene tasks were often neglected due to staffing issues. Nursing notes did not indicate any refusal of care by the resident during the observed period. Resident #27, with severe cognitive impairment and cancer, was also found with dark debris under fingernails and long facial hair. Observations and staff interviews indicated that the resident's hygiene needs were not met, and staff cited dull razors and staffing shortages as reasons for the neglect. Nursing notes did not document any refusal of care by the resident. Similar issues were observed with Resident #46, who had long, soiled fingernails and substantial facial hair growth, and Resident #53, who had long, jagged nails with dark debris and dried blood. Resident #69, diagnosed with Alzheimer's disease and dementia, was observed with long fingernails and caked-on dark orange material in facial hair. Despite being totally dependent on staff for personal hygiene, the resident's needs were not met. Staff interviews confirmed that hygiene care was often delayed or neglected due to staffing shortages. Nursing notes did not indicate any refusal of care by the resident. The facility's policies on fingernail care and shaving were not adhered to, contributing to the deficiencies observed.
Failure to Label Oxygen Tubing
Penalty
Summary
The facility failed to appropriately label oxygen tubing for residents requiring oxygen therapy. Resident #4, diagnosed with anoxic brain damage and other conditions, was observed with unlabeled oxygen tubing despite a physician's order specifying oxygen administration at 2 liters per minute. Similarly, Resident #51, who has COPD and obstructive sleep apnea, was found with unlabeled oxygen tubing, contrary to the physician's order to change and label the tubing weekly. LPN #1 confirmed the tubing was not labeled and subsequently changed it after surveyor inquiry. Resident #57, with non-rheumatic aortic valve insufficiency and dementia, was also observed with unlabeled oxygen tubing, despite a physician's order for oxygen administration as needed. Additionally, Resident #279, diagnosed with COPD and heart failure, reported that staff did not routinely change the oxygen tubing, which was confirmed by RN #1. The facility did not provide a policy for oxygen equipment when requested, indicating a systemic issue in adhering to proper oxygen therapy protocols.
Failure to Complete Annual Performance Appraisals
Penalty
Summary
The facility failed to complete annual performance appraisals for two nurse aides, NA #10 and NA #11. NA #10's last performance appraisal was not dated by either the nurse aide or the next level manager, while NA #11's last performance appraisal was dated five years ago. The Administrator acknowledged the lapse, attributing it to inconsistent staffing and multiple changes in the Director of Nursing (DNS) position. The current DNS was attempting to catch up on tasks left incomplete by previous staff. According to the facility's policy, managers are required to conduct performance appraisals or performance-based conversations with employees at least annually, and in-service education should be provided based on these reviews.
Failure to Monitor Behaviors for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that behavior monitoring was completed for a resident receiving psychotropic medications. Resident #62, diagnosed with dementia with agitation, anxiety, and paranoid personality disorder, was prescribed Risperidone for agitation. Despite the care plan's directive to monitor for changes in mental status and functional level, no behavioral monitoring order was in place from 6/21/23 to 11/6/23. Nurse's notes and psychiatric notes lacked documentation of target behaviors or behavior monitoring, and interviews with staff confirmed the absence of such monitoring in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The Director of Nursing Services (DNS) acknowledged the lack of behavior monitoring and confirmed it was against facility policy, which mandates monitoring for residents on antipsychotic medications every shift. Similarly, Resident #527, admitted with Down Syndrome, Alzheimer's Disease, and diabetes mellitus, was prescribed Olanzapine for behavioral disturbance. The physician's order did not include behavioral monitoring, and a review of the MAR, TAR, and nurse's notes from 10/13/23 to 11/13/23 showed no evidence of behavior monitoring. The DNS confirmed that behavioral monitoring should be conducted for residents with dementia on antipsychotic medications without a psychiatric diagnosis, but was unable to locate any such documentation in the clinical record. The facility's policy on managing behavioral symptoms, which requires staff to monitor and document exhibited behavioral symptoms, was not followed. The lack of behavior monitoring for both residents receiving psychotropic medications indicates a failure to adhere to the facility's policies and procedures. This deficiency was identified through clinical record reviews, facility documentation, and staff interviews, highlighting a significant oversight in the care and monitoring of residents with behavioral and psychiatric needs.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for Resident #61, who was admitted with diagnoses including end-stage renal disease, right above knee amputation, and coronary artery disease. The Resident Care Plan dated 2/25/22 identified the resident as being at risk for oral health or dental care problems due to tooth decay, with interventions including obtaining a dental consultation. Despite oral health evaluations on 2/25/22 and 2/26/23 indicating a dental consult was ordered, the resident had not been seen by a dentist since admission over one year and eight months ago. The resident expressed a desire to see a dentist, and observations confirmed the presence of scattered broken and discolored teeth. Interviews with the Director of Nurses (DNS) and RN #4 revealed that the admitting nurse was responsible for ensuring permission forms for dental services were completed, which had not been done. The DNS confirmed that the resident had not received a dental consultation, and RN #4 indicated that if permission was not obtained on admission, the facility had 24 hours to complete the paperwork. The facility's dental service policy mandates routine dental services, including annual inspections of the oral cavity, which were not provided to Resident #61.
Failure to Ensure Safe Water Temperatures
Penalty
Summary
The facility failed to ensure safe water temperatures in resident areas, as observed on multiple occasions. On 10/31/23, the bathroom sink water temperatures for several residents were found to be significantly above the safe limit of 120 degrees Fahrenheit, with temperatures ranging from 122.6 to 127.0 degrees Fahrenheit. The Director of Maintenance confirmed these findings but believed that temperatures up to 124 degrees Fahrenheit were acceptable. However, the facility policy stated that water temperatures should be between 105 and 120 degrees Fahrenheit. The Director of Maintenance also failed to notify the Administrator of these excessive temperatures and did not follow the proper procedure for adjusting the water temperatures, instead opting to adjust the cold water to bring the hot water down. The Administrator was unaware of the excessive water temperatures until the surveyor's inquiry and confirmed that the water temperature logs from 10/14/23 showed nine resident rooms with temperatures above 120 degrees Fahrenheit. The Director of Maintenance was unable to provide a full month of water temperature logs, only producing logs for 10/14/23. The Administrator acknowledged that the Director of Maintenance had not adhered to the facility's policy for taking water temperatures and stated that she would address this issue with him. The facility's Hot Water Temperatures: Inspection policy, last revised on 6/1/23, directed that hot water temperatures should be tested weekly and documented, but this procedure was not followed correctly.
Failure to Complete Mandatory In-Service Training
Penalty
Summary
The facility failed to ensure that Nurse Aide (NA) #1 and NA #10 completed the mandatory 12 hours of in-service education annually. NA #1 completed only 5.78 hours of online training and attended in-person training sessions on Personal Protective Equipment (PPE) and hand washing, as well as on Abuse, Neglect, and Exploitation, but the duration of these sessions was not specified. Additionally, NA #1 did not receive any dementia care training. NA #10 did not complete any online training but attended the same in-person training sessions as NA #1, also without specified durations, and similarly did not receive dementia care training. An interview with RN #5 revealed that she was responsible for providing the education and in-service training through an online portal and in-person sessions, but she could not explain why the mandatory training was not completed. The facility also failed to provide an annual in-service training policy when requested.
Failure to Use Urinary Privacy Bag
Penalty
Summary
The facility failed to ensure a urinary privacy bag was utilized for Resident #477, who had a suprapubic catheter. Resident #477, diagnosed with a fracture of the left femur, benign prostatic hyperplasia with lower urinary tract symptoms, and dementia, was observed in the dining area with a urinary collection bag attached to the wheelchair without a privacy cover. The Nursing Admission Assessment indicated that Resident #477 required extensive assistance for personal hygiene, bathing, toileting, dressing, and transfers, and had a suprapubic catheter in place. An interview with the Occupational Therapist (OT) who assisted Resident #477 out of bed revealed that she was unaware of the need for a privacy cover for the urinary collection bag. The Director of Nursing (DNS) confirmed that the facility's policy required all urinary collection bags to have a privacy covering and that staff, including the therapy department, were educated on this policy. However, the facility was unable to provide a written policy regarding the use of privacy covers for urinary collection bags.
Failure to Document and Update Advance Directives
Penalty
Summary
The facility failed to ensure that Resident #21's current preference for code status was accurately documented in both the paper and electronic health records. Despite having a Resident Healthcare Instruction form indicating a full code status, a transfer document from a recent hospitalization indicated a Do Not Resuscitate (DNR) status. Interviews with staff revealed confusion and lack of clarity regarding who was responsible for updating the code status in the Electronic Health Record (EHR), leading to discrepancies in the resident's documented preferences. The Director of Nursing Services (DNS) and the Administrator acknowledged the failure to update the advance directive upon the resident's return from the hospital, resulting in conflicting information in the resident's records. Resident #428's medical records also lacked documentation of an advance directive upon admission. Although a State of Connecticut transfer order indicated a DNR status, there was no evidence in the paper chart or EHR that the resident or their representative had been given the opportunity to choose an advance directive. An interview with an LPN confirmed the absence of documentation and the failure to complete the advance directive process upon admission. It was only after surveyor inquiry that a signed advance directive consent and a physician's order were obtained, confirming the resident's DNR status. Similarly, Resident #527's records did not include a physician order or identification of code status in either the paper chart or EHR. The paper chart contained a blank and unsigned Resident Healthcare Instruction form. Interviews with nursing staff revealed that the responsibility for completing an advance directive upon admission was unclear, and no advance directive was obtained for the resident during their stay. Subsequent to surveyor inquiry, efforts were made to contact the resident's representative to obtain the necessary documentation. The facility's policy requires that code status be easily accessible and documented as part of the admission order set, which was not adhered to in these cases.
Failure to Notify Resident Representative of Significant Weight Loss
Penalty
Summary
The facility failed to ensure that the representative of a resident with dementia, myocardial infarction, and hypertension was notified of a significant weight loss. The resident, who was severely cognitively impaired and required assistance with eating, experienced a weight loss from 139.1 lbs to 133.7 lbs between July 1, 2023, and August 1, 2023, which was a 7.6% weight loss. Despite a physician's order to weigh the resident monthly and a care plan that included monitoring for unplanned weight loss, the resident's representative was not informed of this significant change. Further review showed that the resident's weight continued to decline, reaching 127.1 lbs by October 2, 2023, marking an 8.6% weight loss over three months. The dietician confirmed the significant weight loss trend but admitted that the facility lacked a specific policy for notifying family or representatives of such changes. The dietician also noted that no single person was responsible for making these notifications, indicating a systemic issue in communication and responsibility within the facility's team.
Failure to Ensure Resident's Right to be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure Resident #527's right to be free from physical restraints. Resident #527, who had diagnoses including Down Syndrome, Alzheimer's Disease, and diabetes mellitus, was admitted with psychiatric and behavioral issues. The resident exhibited behaviors such as agitation, restlessness, and attempts to self-transfer, which placed them at risk for falls. Despite these behaviors, the facility's care plan and interventions did not adequately address the resident's needs, leading to an incident where the resident was found restrained to their wheelchair with a bed sheet tied around their waist by a nursing assistant (NA) due to insufficient staffing and inability to provide one-to-one supervision. On the day of the incident, the facility was short-staffed, with only one NA present initially, and additional NAs arriving later in the shift. The NA who restrained Resident #527 reported feeling overwhelmed by the resident's behaviors and the demands of other residents, leading her to use the restraint as a temporary measure to prevent the resident from falling or causing harm. The restraint was discovered by a Speech Language Pathologist (SLP), who removed it and reported the incident to the charge nurse and her supervisor. However, there was a delay in reporting the incident to higher management, and conflicting accounts from staff about who was informed and when. Interviews with facility staff, including the Director of Nursing Services (DNS) and the Administrator, revealed ongoing issues with staffing shortages and inadequate supervision for residents with high behavioral needs. The DNS and Administrator acknowledged the challenges in providing appropriate care for Resident #527 and the lack of specific interventions in the care plan to manage the resident's behaviors. The facility's policy prohibited the use of physical restraints not required to treat medical symptoms, highlighting a significant deficiency in ensuring resident safety and compliance with regulatory standards.
Failure to Timely Report Allegation of Mistreatment
Penalty
Summary
The facility failed to report an allegation of mistreatment involving Resident #527 to the state agency in a timely manner. Resident #527, who had diagnoses including Down Syndrome, Alzheimer's Disease, and diabetes mellitus, was admitted with psychiatric and behavioral issues. The resident required extensive assistance for mobility and toileting and had a care plan addressing behavioral problems and fall risks. On a specific date, the resident was found restrained to a wheelchair with a bed sheet tied around the waist, an act admitted by NA #12. However, the incident was not reported to the RN Supervisor or managerial staff until three days later, and the Administrator delayed reporting to the state agency until the following day, citing a lack of information from a witness as the reason for the delay. The facility's policy on Abuse, Neglect, and Exploitation mandates immediate reporting of suspected abuse to a supervisor and subsequent reporting to the Administrator or designee within two hours. Despite this policy, the Administrator acknowledged awareness of the two-hour reporting window but failed to comply. The delay in reporting the incident to the state agency constitutes a deficiency in adhering to the facility's abuse reporting protocols.
Failure to Update Care Plans and Implement Interventions
Penalty
Summary
The facility failed to update and implement new interventions in the care plans for several residents following significant events. Resident #6, who had diagnoses including muscle weakness, Alzheimer's disease, and seizures, experienced two falls on 10/14/23 and 10/31/23. Despite these incidents, the care plan was not updated with new interventions to prevent future falls, and the existing intervention of using a floor mat was not consistently implemented. Additionally, the facility's policy of closely monitoring residents after a fall was not followed, as evidenced by the unwitnessed fall in the dining room on 10/31/23. Resident #9, with diagnoses including pneumonia, urinary tract infection, dementia, and bipolar disorder, developed an unstageable pressure ulcer on the left heel. The care plan, which initially did not include a turning or repositioning schedule, was not updated to reflect the resident's increased need for assistance following a decline in condition. Despite the worsening of the pressure ulcer, no new interventions were added to the care plan to prevent further deterioration. Resident #68, admitted with Alzheimer's dementia and an infection of the right hip prosthesis, experienced an unwitnessed fall on 10/27/23. The care plan was not revised to include additional interventions to prevent future falls, even though a physical therapy evaluation identified multiple fall risk factors. Similarly, Resident #527, with diagnoses including Down Syndrome, Alzheimer's Disease, and diabetes mellitus, exhibited behaviors that increased the risk of falls and injury. The care plan did not provide specific interventions for staff to implement when the resident exhibited these behaviors, leading to an incident where the resident was improperly restrained with a bed sheet for safety reasons.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for Resident #23, who was admitted with diagnoses including chronic kidney disease, total hip arthroplasty, and gout. The resident was cognitively intact and required extensive assistance with bed mobility, toilet use, and personal hygiene. Despite a physician's order dated 8/25/23 to consult podiatry as needed, no referral to podiatry was noted in the medical record. On 9/7/23, a physician's progress note identified that Resident #23's right great toe was swollen, yet no podiatry consult was made. Observations on 11/7/23 revealed that Resident #23's toenails were long and curling forward, and Person #2 confirmed having requested foot care for the resident multiple times without any action taken. Interviews and clinical record reviews indicated that any staff member could have brought concerns about the resident's toenails to the nurse, who would then request a podiatry consult. However, RN #1 was unable to locate any record of concerns being raised by the family or staff regarding the resident's toenails. The facility's Foot Care policy, dated 8/7/23, directed that residents with complicating disease processes requiring foot care must be referred to qualified professionals such as podiatrists. This policy was not followed, resulting in the deficiency noted in the report.
Failure to Implement Fall Prevention Measures and Conduct Risk Assessments
Penalty
Summary
The facility failed to ensure care plan interventions were implemented, provide adequate supervision to prevent falls, and conduct risk assessments following falls for three residents. Resident #6, diagnosed with muscle weakness, Alzheimer's disease, and seizures, was identified as a fall risk. Despite care plan interventions such as the use of floor mats and encouraging the use of a call bell, Resident #6 experienced two falls. Observations revealed that the resident's bed was in a high position without floor mats, contrary to the care plan. Interviews with staff indicated inadequate monitoring and insufficient staffing during the incidents, leading to unwitnessed falls and non-compliance with the fall protocol. Resident #68, admitted with Alzheimer's dementia and an infection of the right hip prosthesis, was initially assessed as a low fall risk. However, after an unwitnessed fall, it was found that quarterly fall risk assessments had not been completed since admission, and no fall risk assessment was conducted post-fall. The Director of Nursing confirmed the lapse in protocol, and the Physical Therapist classified the resident as a high fall risk based on a subsequent evaluation. Resident #527, with diagnoses including Alzheimer's disease, bacterial pneumonia, and Type 2 Diabetes, was identified as a high fall risk upon admission. Despite this, after a witnessed fall, the facility failed to complete a fall risk assessment post-fall. Instead, the facility's process involved a Nursing Change of Condition Evaluation and a verbal referral to Physical Therapy, which did not align with the facility's fall management policy. The Director of Nursing acknowledged the failure to follow the policy, which required reassessments after falls to minimize recurrence and risk.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide timely notification to the Ombudsman regarding multiple transfers of a resident to the hospital. Resident #21, who had diagnoses including heart failure, anemia, and dementia, experienced several medical emergencies that required hospital transfers. These incidents included elevated temperature, falls with head injuries, dislodged cholecystectomy drain, abnormal vital signs, and other acute conditions. Despite these transfers, the facility did not notify the Ombudsman as required by their policy and federal regulations. Interviews with the Social Worker and the Ombudsman revealed that the facility's process for notifying the Ombudsman was inadequate. The Social Worker indicated that notifications were made using an online reporting system every 30 days, but documentation of these reports was not provided. The Ombudsman confirmed that Resident #21's transfers were not reported, and only three months of reporting appeared in the system from 2021 to the present. The facility's Discharge and Transfer Policy required verbal and written notifications to the resident and their representative, as well as copies of notices to the Ombudsman, which were not adhered to in this case.
Failure to Notify Resident Representative of Bed Hold Policy
Penalty
Summary
The facility failed to provide the required notification of the bed hold policy for a resident with diagnoses including heart failure, anemia, and dementia. The resident was moderately cognitively impaired and required supervision and assistance for daily activities. Despite multiple hospital transfers and returns, the facility did not consistently notify the resident's representative in writing about the bed hold policy as required. Specifically, notifications were missing for hospital admissions on several dates, including 9/25/22, 12/1/22, 12/24/22, 1/29/23, 2/12/23, 7/29/23, and 8/14/23. The Business Office Manager (BOM) acknowledged the oversight and indicated that the responsibility for completing the Bed Hold Notice of Policy & Authorization form had recently shifted from the Admissions department to the Business Office. The facility's policy mandates that the resident or their representative be notified in writing about the bed hold policy upon each transfer, with the notice delivered via email, fax, or mail within 24 hours if the representative is not present. However, this procedure was not followed for the specified hospital admissions, resulting in a failure to comply with the notification requirements.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 328 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Apple Rehab Guilford | 0.5 mi | — | 2 | 0 |
| Guilford House, The | 4.8 mi | — | 2 | 0 |
| Evergreen Woods | 6.2 mi | — | 0 | 0 |
| Ark Healthcare & Rehabilitation At Branford Hills | 10.9 mi | — | 20 | 0 |
| Aaron Manor Nursing & Rehabilitation | 11.5 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.