Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Chi Franciscan Villa during CMS and state inspections, most recent first.
A resident with multiple comorbidities, comatose status, and total dependence for mobility developed a facility-acquired stage 3 buttock pressure injury and an unstageable DTI on the ankle despite documented risk and care plan interventions such as an air mattress, q2h repositioning, and bilateral heel boots. Surveyors observed on multiple occasions that the resident was lying on her back without pressure-relieving boots and with feet not properly offloaded, sometimes resting directly on the mattress or laterally on a flattened pillow. The facility lacked a detailed pressure injury policy, did not document a root cause for the stage 3 injury, and did not update the care plan to address the development of the new pressure injury.
Two residents did not receive adequate supervision and safety measures to prevent accidents. One resident with severe cognitive impairment, wandering behavior, and a documented fall risk had a care-planned low bed intervention that was not in place; the bed was found at waist height after the resident was discovered walking in the hall with facial bleeding, and documentation indicated the resident likely raised the bed using the remote. The facility’s investigation did not explain the lack of supervision or why the low-bed intervention was not in place despite documented restlessness and wandering. Another resident with a trach, chronic respiratory failure, dysphagia, and functional quadriplegia had speech therapy and care plan orders for a mechanical soft diet, supervision with meals, and use of a Passy Muir speaking valve during all PO intake, yet was observed eating independently without supervision and later with a meal tray present, no PMSV in place, and no staff supervision for an extended period, contrary to the facility’s own meal supervision policy.
The facility failed to provide sufficient nursing staff to meet residents’ needs, as shown by PBJ data and schedules indicating frequent understaffing of CNAs, nurses, and CMAs, especially on weekends. Staff interviews revealed that frequent call-ins led to short staffing, requiring nurses to assist with CNA tasks and causing staff to fall behind, with acknowledgment that residents were affected. Surveyors observed delayed responses to call lights, including one resident whose call light remained on for 16 minutes while staff walked by, and another resident who requested bathroom assistance, had the call light turned off and was told to wait, then had to reactivate the call light and wait several more minutes before help arrived. The NHA acknowledged past staffing challenges but provided no further explanation for the low staffing or delayed call light responses.
A resident with CHF, lymphedema, morbid obesity, PVD, and a history of falls, who was cognitively intact and required assistance with bathing, transfers, and dressing, was observed being wheeled in a shower chair down facility hallways by a CNA while wearing a hospital gown that left the resident’s hip and side of the buttocks exposed. This transport route passed the main entrance and multiple hallways, contrary to the facility’s dignity policy requiring protection of bodily privacy during personal care. The resident later stated dissatisfaction with being exposed and indicated not knowing the skin was uncovered.
A resident with complex medical conditions, including anoxic brain damage, respiratory failure with hypoxia, trach and G-tube status, morbid obesity, CHF, and a comatose BIMS score, was the subject of a family grievance alleging inadequate turning and repositioning, feces on sheets, infrequent checks, and possible trach infection. The grievance form showed that the SW and DON met with the guardian and marked the concern as resolved, but there was no documented investigation, findings, confirmation status, or corrective actions as required by the facility’s grievance policy. The current DON could not locate any additional follow-up documentation, and the resident’s guardian reported that the same care concerns continued and that no changes were made after the grievance was filed.
A resident with Alzheimer’s disease, delirium, and CKD stage 3B, who was documented as rarely/never understood and exhibiting behavioral symptoms, had a missing wedding ring reported by the spouse to facility staff, who completed a grievance form and confirmed the ring was not among the resident’s belongings. The spouse subsequently reported the missing white gold diamond wedding ring to local police after being told by the Admissions Director that the ring was not at the facility. Despite the facility’s abuse policy identifying missing property as a possible indicator of abuse, the NHA did not treat the incident as misappropriation, stating the spouse indicated it was misplaced, and the allegation was not reported to the State Survey Agency within the required timeframe, resulting in a delayed report of suspected misappropriation.
A resident with chronic respiratory failure, an indwelling trach, chronic encephalopathy with delirium, and multiple comorbidities repeatedly pulled out her trach tube, an event documented at least 28 times and leading to numerous 911 calls and ER transfers when reinsertion was unsuccessful. Although the care plan addressed general trach care and anti-anxiety medication use, it did not include specific, person-centered interventions for the resident’s ongoing behavior of removing the trach. The DON acknowledged the behavior occurred daily and cited increased Ativan use, proximity of the resident’s room to the nurses’ station, and a believed but undocumented psych consult request, yet the surveyor found no evidence of additional interventions or a comprehensive behavior-focused care plan, and trach care and treatment were not included in the Facility Assessment.
A resident with multiple medical conditions and intact cognition, who required supervision and assistance for bathing and dressing per the care plan, did not receive the ordered twice-weekly showers on numerous scheduled dates over several months. The resident reported not getting daily showers and could not recall the last one, and was observed wearing food-stained clothing. Facility policy required support for ADLs, including hygiene, and the DON stated CNAs must complete shower sheets and document refusals, but no shower documentation could be produced for the missed dates.
A resident with Alzheimer’s disease, delirium, and CKD stage 3B was receiving warfarin and clopidogrel without a baseline care plan for anticoagulant/antiplatelet monitoring. The resident got out of bed, pulled out an indwelling Foley catheter, left the room, and fell, after which an RN documented abrasions, penile bleeding from traumatic catheter dislodgement, and reinsertion of the catheter with initial blood clots. Over the following hours, staff documented ongoing hematuria, dried blood around the genital area, and a Foley that appeared partially dislodged, and the unit manager later stated the resident was being monitored on a 24-hour board, but no supporting documentation of monitoring or serial assessments was produced. Surveyors found limited documentation of assessment and monitoring of the resident’s hematuria and condition during the several hours between the fall/catheter trauma and the resident’s eventual transfer to the hospital for hematuria.
A resident's legal representative was not granted access to medical records after submitting a written request, even after being named Power of Attorney for Health Care. The facility did not act on the request following the change in the resident's decision-making status, resulting in the records not being released.
Two residents experienced deficiencies in accident prevention and fall risk management. One resident fell from bed and sustained a femur fracture when a CNA failed to follow proper turning protocols during care. Another resident, at risk for falls, did not have required reminder signage or trip hazards removed from their room, and their fall risk assessment was not accurately completed, leading to a fall during an attempted self-transfer.
A resident with significant medical conditions developed a new unstageable pressure ulcer on the left posterior ankle, which was not present on prior assessments. The facility did not notify the resident's representative of this new injury, as required by policy, and documentation confirming such notification was absent. The DON confirmed the omission after reviewing the records.
A resident with complex medical needs, including a tracheostomy and persistent vegetative state, had multiple instances of missing documentation in the electronic medical record for essential care tasks such as suctioning assessments, trach site cleansing, and inner cannula changes. Nursing staff and the DON confirmed that these omissions in the Treatment Administration Record indicated the required care may not have been performed as ordered.
A resident with a tracheostomy and complex medical history received care during which the RT failed to disinfect the table before placing supplies, contaminated sterile gloves by touching them with dirty gloves, and did not perform required hand hygiene or glove changes between steps. These actions did not follow the facility's infection control policy for tracheostomy care.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were insufficient to minimize accident risks.
The facility did not fully investigate an allegation of narcotic medication misappropriation after controlled medication discrepancies were found involving a nurse. Although several residents were affected, not all had documented pain evaluations or interviews to assess outcomes, and the investigation lacked complete documentation for all potentially impacted individuals.
The facility did not report a suspected diversion of narcotic medications to the State Survey Agency within the required timeframe after discovering multiple controlled medication discrepancies involving an RN. The incident was reported late due to internal investigation and corporate direction.
The facility failed to ensure that a DT received required supervision from an RD in the assessment and ongoing nutritional care of two residents, including those with pressure ulcers, diabetes, recent stroke, and significant weight loss. The DT completed nutritional assessments and progress notes without RD review or consultation, and the RD was unaware of high-risk cases and did not routinely review or sign off on assessments.
A resident's MDS assessments were inaccurately coded, with the quarterly assessment reflecting an incorrect weight and the discharge return anticipated assessment documenting an incorrect number of unstageable wounds. The errors were confirmed by the MDS Coordinator, despite facility policy and RAI manual requirements for accuracy.
Two residents dependent on staff for bathing did not consistently receive scheduled showers, and staff failed to properly document refusals or interventions as required by facility policy. Incomplete records and lack of nurse sign-off were found, despite care plans and orders specifying the need for substantial or total assistance and thorough documentation.
A resident with severe cognitive impairment, stroke, and swallowing difficulties experienced significant weight loss after admission due to inadequate oversight by the RD over the DT. The DT completed the nutritional assessment and made care plan changes without the RD's knowledge, and the resident was frequently left without proper feeding assistance, resulting in poor meal intake and further weight loss.
Staff did not follow enhanced barrier precautions during wound care for a resident with venous stasis ulcers. Despite clear facility policy and signage requiring the use of gowns and gloves for chronic wound care, staff only wore gloves and omitted gowns. The nurse involved believed gowns were only necessary for draining wounds, contrary to the facility's policy, which was confirmed by the unit manager.
A resident with quadriplegia was subjected to verbal and mental abuse by a CNA who removed the resident's call light and closed the door, leaving them unable to summon help. The incident was not reported to the NHA immediately, allowing the CNA to continue working for additional shifts. This failure to protect the resident and report the abuse promptly resulted in a finding of immediate jeopardy.
A facility failed to report an allegation of abuse immediately, allowing a CNA accused of misconduct to continue working for three additional shifts. The incident involved a resident with quadriplegia, whose call light was removed by the CNA. The RN who was informed of the incident did not report it to the administration, delaying the investigation and reporting to the State Survey Agency.
The facility allowed CNAs to administer medications on the Heritage unit during a nurse shortage, contrary to policy and state regulations. The DON instructed CNAs to deliver medications under RN supervision, a practice not permitted without specific training. The NHA was aware but deferred to the DON's decision.
Three residents experienced verbal abuse from two staff members, with one CNA threatening and ridiculing residents during mealtime, and another CNA making racially insensitive remarks during ostomy care. The incidents were reported by witnesses, leading to administrative actions against the involved staff.
Failure to Implement Pressure Injury Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and treatment consistent with professional standards of practice for a resident who was at high risk for skin breakdown. The resident was admitted with multiple serious medical conditions, including anoxic brain damage, acute respiratory failure with hypoxia, tracheostomy and gastrostomy status, morbid obesity, congestive heart failure, major depressive disorder, and anxiety. The resident’s MDS documented that she was comatose, had impaired upper and lower extremities bilaterally, was dependent on staff for rolling and mobility in bed, and was at risk for development of pressure injuries. The Care Area Assessment noted she was at risk for skin impairment and that preventive measures such as a pressure-reducing mattress, wheelchair cushion, and weekly skin checks were in place. Her CNA Kardex and care plan documented that she required two staff for repositioning every two hours and bilateral heel boots to offload pressure to her heels, and that she had an air mattress set to her weight for wound prevention and healing. Despite these identified risks and documented interventions, the resident developed a facility-acquired stage 3 pressure injury on the left buttock and an unstageable deep tissue injury (DTI) on the right lateral ankle. Wound physician notes described an unstageable DTI of the right lateral ankle with intact skin and purple/maroon discoloration and a stage 3 pressure wound of the left buttock with full-thickness tissue loss and granulation tissue. Subsequent wound notes continued to document the unstageable DTI on the right lateral ankle and the stage 3 pressure injury on the left buttock. The facility did not provide a pressure injury policy and procedure to surveyors, only a general “Pressure Injuries Overview” form that contained definitions and staging information but no procedural guidance. Surveyors observed multiple instances where the resident’s care plan interventions for pressure relief were not implemented. On several observations over multiple days, the resident was seen lying on her back in bed without pressure-relieving boots, with her feet either resting laterally on a pillow or directly on the mattress, and not properly offloaded. Only one observation noted a pillow under her legs to float her heels, but the pillow was flattened and both feet were still resting laterally on the pillow. The facility did not document a root cause for the development of the stage 3 left buttock pressure injury, and the resident’s care plan was not updated to include interventions addressing the potential root cause of that pressure injury. When questioned, the DON stated the facility believed the root cause was related to the incontinence product edge lying over the wound, but no additional information was provided explaining why the DTI and stage 3 pressure injury developed or why the ordered preventive interventions were not in place as observed by surveyors.
Failure to Provide Adequate Supervision and Safety Measures to Prevent Falls and Choking
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. One resident with Alzheimer’s disease, severe cognitive impairment (BIMS score of 5), wandering behavior, and a documented fall risk score of 10 had a care plan intervention for the bed to be in the lowest position. Despite this, on the day of the incident, the resident’s bed was found at about waist height after the resident had been seen resting in bed in the lowest position 20–30 minutes earlier. The resident was later found walking in the hallway with a walker, bleeding from the head, face, nose, and mouth, and staff documentation and the fall protocol checklist indicated that the bed was high and that the resident likely raised the bed using the remote, which was found next to the side rail. The same resident had prior documentation of restlessness, combative behaviors, and wandering into other residents’ rooms on the day of the fall. Nursing notes indicated the resident was being monitored for these behaviors and that she was easily redirected and cooperative, but the facility’s fall investigation and self-report did not address why adequate supervision was not provided at the time of the fall, despite these behaviors. The surveyor noted that the fall intervention of a low bed was not in place at the time of the fall and that no additional information was provided by facility leadership explaining the lack of supervision and the absence of the low-bed intervention when the fall occurred. A second deficiency involved another resident with chronic respiratory failure, tracheostomy status, laryngeal hypoplasia, epilepsy, obesity, functional quadriplegia, type 2 diabetes, and dysphagia, who had speech therapy recommendations and a care plan requiring a mechanical soft diet, supervision during meals, and use of a Passy Muir speaking valve (PMSV) during all PO intake. The facility’s own Meal Supervision and Assistance policy required adequate supervision during meals based on assessed needs and identified risks. During one observation, the resident was found in bed with a lunch plate on the lap, eating independently and having consumed at least half of the meal before a unit manager entered, placed a cap on the trach, and stated she would stay because the resident needed supervision when eating. On another observation, the resident was lying in bed with the head of bed elevated, the lunch tray in front, the PMSV not in place, and no staff entering the room to supervise for 27 minutes, despite the documented need for supervision with meals and PMSV use during all PO intake.
Insufficient Nursing Staff and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, particularly during October, as evidenced by staffing records, staff interviews, and call light response observations. Review of PBJ (Payroll Based Journal) data from July through December showed the facility triggered for one-star staffing and excessively low weekend staffing, with October schedules and daily staffing postings revealing that on 21 of 31 days, CNA staffing did not meet the facility’s own deemed appropriate numbers, and all four weekends were understaffed. Nurse and Certified Medication Assistant staffing was also below the facility’s targets on six days, four of which were weekends when CNA staffing was also short. Staff interviews, including CNAs, an LPN, a CMA, and the scheduler, consistently cited frequent call-ins as a cause of short staffing and acknowledged that nurses had to assist with CNA duties, that staff got behind, and that residents were affected when shifts were short. Surveyors directly observed delayed responses to resident call lights, further demonstrating the impact of insufficient staffing on resident care. One resident’s call light remained activated for 16 minutes while multiple staff members walked past the room before anyone entered. In another instance, a CNA entered a resident’s room after a call light was activated, was told the resident needed to use the bathroom, turned off the call light, instructed the resident to wait, and left; the resident reactivated the call light 10 minutes later, and it was approximately five minutes more before another staff member entered the room. The Nursing Home Administrator acknowledged staffing challenges in October and November and stated that nurse managers were present on weekends providing care, but the facility did not provide additional information to address the surveyor’s concerns about low staffing or the delays in answering call lights.
Resident Exposed During Transport to Shower, Violating Dignity and Privacy
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and bodily privacy during transport to the shower. A surveyor observed a certified nursing assistant (CNA-C) wheeling Resident 7 down the South hallway, past the main entrance, and halfway down the North hallway to the shower room while the resident was seated in a shower chair wearing a hospital gown with the left hip and side of the buttocks exposed. The facility’s undated “Dignity” policy states that each resident shall be cared for in a manner that promotes well-being, self-worth, and self-esteem, and that staff must promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures. Resident 7 had been admitted with diagnoses including congestive heart failure, lymphedema, morbid obesity, peripheral vascular disease, and a history of falls, and had a BIMS score of 14 indicating intact cognition. The resident’s care plan documented needs for partial to moderate assistance with bathing and showering, and supervision or assistance with ambulation, transfers, and dressing. After the observed incident, the resident reported being unhappy that her skin was exposed while being wheeled through the hallways to the shower and stated she did not know her skin was exposed and that she was not an exhibitionist. The nursing home administrator and DON were notified of these dignity concerns and acknowledged them.
Failure to Follow Grievance Policy and Document Resolution of Care Concerns
Penalty
Summary
The facility failed to follow its grievance policy and ensure prompt resolution and proper documentation of a grievance related to a resident’s care. A resident with anoxic brain damage, acute respiratory failure with hypoxia, tracheostomy and gastrostomy status, morbid obesity, congestive heart failure, major depressive disorder, anxiety, and a BIMS score indicating coma was the subject of a grievance filed by the resident’s family/guardian. The written grievance documented concerns that the resident was not being turned as frequently as needed, had feces on the sheets, was not being checked on as often as the family desired, and that the tracheostomy might be infected. The grievance form noted that the SW and DON met with the guardian, that the family wanted the resident checked at a hospital for possible trach infection, and that the concern was marked as resolved with the family reportedly satisfied with the plan. Despite the facility’s written policy requiring the Grievance Official to oversee the process, investigate, and issue a written decision including the steps taken, findings, confirmation status, and corrective actions, there was no evidence of follow-up or resolution beyond the initial notation on the grievance form. The current DON reported she had no additional information and could not locate any further documentation related to the grievance. The resident’s guardian later stated that the same concerns about turning, repositioning, checking on the resident, use of boots, and development of bed sores persisted and that no one addressed or changed anything after the grievance was filed. Surveyors found no additional information when the NHA and DON were notified of concerns regarding grievances.
Failure to Timely Report Allegation of Misappropriation of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to timely report a reasonable suspicion of a crime, specifically an allegation of misappropriation of a resident’s property, to the State Survey Agency as required by Section 1150B of the Act and the facility’s own Abuse, Neglect, and Exploitation policy. The policy, effective 5/22/25, identifies resident reports of theft or missing property as possible indicators of abuse that require action. The resident involved had Alzheimer’s disease, delirium, and stage 3B chronic kidney disease, and was documented on the Admission/Medicare 5-day MDS as rarely/never understood and rarely/never understanding others, with behavioral symptoms occurring 1–3 days in the look-back period. On 12/2/25, the resident’s wife called the facility and reported that the resident’s wedding ring was missing; staff documented this on a Resident/Family Concern/Grievance Report form, and the ring was not found among the resident’s belongings. On 12/3/25, the resident’s wife went to the South Milwaukee Police Department and reported that she had contacted the facility and spoken with the Admissions Director, who confirmed they did not have the ring. She stated she last saw the ring on the resident’s finger on November 30 and described it as a white gold men’s wedding ring with diamonds. Despite this report to the facility and the subsequent police report, the allegation of misappropriation was not reported to the State Survey Agency until 12/9/25, outside the required timeframe. During an interview on 2/17/26, the Nursing Home Administrator stated that the wife never indicated the ring was stolen, only misplaced, and therefore the incident was not reported as misappropriation. The surveyor informed the administrator that the missing wedding ring constituted an allegation of misappropriation that should have been reported on 12/2/25, and later informed the DON of the concern regarding the delayed reporting. No additional information was provided regarding the delay in reporting the allegation to the State Survey Agency.
Failure to Develop Comprehensive Care Plan for Resident Repeatedly Removing Tracheostomy Tube
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s repeated behavior of pulling out her tracheostomy tube. The resident was admitted with multiple complex diagnoses, including chronic respiratory failure with an indwelling tracheostomy, chronic encephalopathy with delirium, laryngeal hypoplasia, epilepsy, anxiety disorder, obesity, functional quadriplegia, dysphagia, and type 2 diabetes mellitus. Her History and Physical documented that she remains in a chronic encephalopathic state with delirium and repeatedly pulls out tubes and her tracheostomy at the nursing home. The existing care plan noted that she has a tracheostomy and is at risk for shortness of breath, with approaches such as ensuring trach ties are secured and outlining tube-out procedures, and it also documented that she uses anti-anxiety medications and that she pulls out her trach often, with approaches limited to administering anti-anxiety medications and monitoring for side effects and effectiveness. Despite documentation in the H&P and progress notes that the resident has pulled out her trach tube at least 28 times since admission, resulting in at least 18 calls to 911 and transfers to the ER when staff could not reinsert the tube, the facility did not create or implement a specific care plan with targeted interventions for this behavior. The DON reported that the resident pulls out her trach daily, sometimes multiple times a day, and stated that Ativan had been increased and that the hospital uses wrist restraints, which the facility does not use. The DON also stated she thought the facility had requested a psychiatric consultation that was refused by the resident’s son, but she was unable to provide evidence that such a consult was ordered or refused. The DON further reported that the resident’s room placement near the nurses’ station allowed for more frequent checks, but the surveyor found no evidence of implemented interventions beyond increasing Ativan, and noted that tracheostomy care and treatment were not included in the Facility Assessment.
Failure to Provide Scheduled Showers and Maintain Resident Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, specifically bathing and hygiene, to maintain a resident’s grooming and personal hygiene as required by facility policy and the resident’s care plan. The facility’s ADL policy states that residents who cannot independently perform ADLs will receive services to maintain good grooming and personal hygiene, including assistance with bathing, dressing, and grooming in accordance with the plan of care. The resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including dysphagia, cerebral infarction, COPD, CHF, and muscle weakness, required supervision or touching assistance for showering, bathing, dressing, transfers, and walking with a walker, and was care planned to receive supervision or touching assistance by one staff for bathing and moderate assistance for lower body dressing. Despite the care plan and an EMR order for twice-weekly showers, the resident did not receive documented showers on multiple scheduled dates over several months, including numerous missed showers in July, August, September, and October. During an interview, the resident reported not receiving a daily shower and was unable to recall the last shower. On observation, the resident was seen sitting in a recliner wearing personal clothes that were soiled with food stains on the shirt and pants. The DON stated that CNAs are required to complete shower sheets and document refusals, and that these sheets are kept for about one month, but the facility was unable to produce any shower sheets for the resident and acknowledged concerns about the lack of documented showers on the identified dates.
Failure to Monitor Anticoagulated Resident After Traumatic Foley Catheter Dislodgement
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice for a newly admitted resident who was on both an anticoagulant (warfarin) and an antiplatelet (clopidogrel). The resident had diagnoses including Alzheimer’s disease, delirium, and stage 3B chronic kidney disease, and the MDS documented severe communication impairment and behavioral symptoms. Despite physician orders for warfarin and clopidogrel, there was no baseline care plan created for monitoring the resident’s use of these blood-thinning medications, and the DON later acknowledged there would be an expectation for monitoring for bleeding and bruising and PT/INR labs for warfarin. On the night in question, the resident got out of bed, pulled out the indwelling Foley catheter, left the room, and fell outside the room door. A Fall Protocol Checklist recorded the fall time as 23:30, while an RN progress note documented the event at 00:30, creating a discrepancy in the recorded time of the fall. The RN note described the resident as aggressive toward staff, with abrasions to the left forearm and left lower back, and bleeding from the penis likely due to traumatic catheter dislodgement. The RN reinserted the catheter, noting initial drainage of blood clots that then thinned out, and documented the resident’s complaint of bladder pain. Following this event, the resident continued to have hematuria. A medication administration note the next morning documented that the resident was in pain from the dislodged Foley, had hematuria in the Foley line and bag, that the Foley appeared partially out, and that there was dried blood around the penis. A subsequent progress note documented dried blood around the penis, groin, and right leg, blood throughout the Foley tubing and into the bag, and that the Foley securement device suggested the catheter had been pulled and dislodged. The unit manager reported that hematuria had been noted the previous day and that the resident was being monitored on a 24-hour board, but no documentation of such monitoring or ongoing assessments was provided. Surveyors identified a lack of documented assessments and monitoring of the resident’s hematuria and condition during approximately eight hours between the catheter trauma and the resident’s transfer to the hospital for hematuria.
Failure to Provide Medical Records to Legal Representative After POA Activation
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident's medical records to the resident's legal representative after a written request was made. Initially, the resident was responsible for their own decisions, and the family member's request for records was denied because the Power of Attorney for Health Care (POAHC) had not yet been activated. The facility's policy required a properly executed authorization from the resident or their legal representative for release of records. The family member signed an authorization form, but it was not valid since the resident had not authorized it and was in the hospital at the time. Subsequently, the resident's POAHC was activated, naming the same family member as the legal representative. Despite this change in status, the facility did not revisit or act upon the original request for medical records. Interviews with the POAHC agent and the Nursing Home Administrator confirmed that the request remained unaddressed after the POAHC was activated, and no records were provided to the legal representative. The resident had diagnoses including End Stage Renal Disease, altered mental status, and a stage 4 sacral pressure ulcer at the time of the incident.
Failure to Prevent Accidents and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for two of three residents reviewed. One resident, with diagnoses including cerebral palsy, hemiplegia, and mild cognitive impairment, required total assistance for incontinence care and personal hygiene. During daily ADL care, a CNA attempted to turn the resident away from themselves to perform incontinence care, resulting in the resident rolling out of bed and sustaining a displaced intertrochanteric fracture of the right femur. Staff interviews revealed that facility training instructs staff to roll residents toward themselves or to seek assistance if a resident must be turned away, but this protocol was not followed in this instance. Another resident, with a history of epilepsy, breast cancer, and chronic pain syndrome, was identified as being at risk for falls and required supervision for bed mobility and transfers. The resident's care plan included interventions such as placing reminder signs in the room and removing trip hazards, but these interventions were not implemented. The resident experienced a fall while attempting to self-transfer from a wheelchair to a commode. During the survey, a folded-up sheet was observed on the floor in the resident's room, which staff acknowledged as a trip hazard, but it had not been addressed or documented in the care plan. Additionally, the required reminder signage was not present in the room. The facility's fall risk evaluation for the second resident was not completed accurately, as the assessment failed to account for the number of high-risk medications the resident was taking, which would have resulted in a higher fall risk score. Staff interviews confirmed that the fall risk evaluation was not properly completed, and there was a lack of clarity among staff regarding the process for addressing resident requests that may pose safety risks. These deficiencies demonstrate a failure to implement and monitor individualized interventions and assessments as outlined in the facility's own policies.
Failure to Notify Representative of New Pressure Ulcer
Penalty
Summary
The facility failed to notify a resident's representative of a newly developed pressure ulcer. Record review showed that the resident, who was in a persistent vegetative state with diagnoses including acute respiratory failure, anoxic brain damage, and congestive heart failure, was readmitted to the facility. Initial skin checks and hospital discharge documents did not indicate a wound on the resident's left posterior ankle. However, a wound care provider later documented an unstageable, full-thickness pressure ulcer with necrosis on the left posterior ankle, noting it as present on admission per staff. Despite this new finding, there was no documentation in the nursing progress notes that the resident's representative was notified of the pressure injury. The Director of Nursing confirmed that the representative should have been notified when the wound was identified by the wound care provider. The facility's policy requires notification of the resident, physician, and family or legal representative when significant changes, such as the development of a pressure injury, occur. Interviews with staff and review of records confirmed the lack of required notification.
Incomplete Medical Record Documentation for Resident with Tracheostomy
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident with significant medical needs, including acute respiratory failure with hypoxia, anoxic brain damage, and congestive heart failure. The resident was documented as being in a persistent vegetative state with a tracheostomy. Review of the electronic medical record revealed missing documentation in the Treatment Administration Record (TAR) for several critical care tasks, including assessment for suctioning every two hours and as needed, cleansing of the tracheostomy site every shift, and changing or cleaning the inner cannula every 12 hours. Specific dates and times were identified where the required documentation was absent, as evidenced by empty boxes with no nurse initials. Interviews with a registered nurse and the Director of Nursing confirmed the missing documentation on the TARs for the months reviewed. Both staff members acknowledged that the absence of documentation meant the tasks may not have been completed as ordered, as the process requires nurses to sign off on each task as it is performed. The deficiency was limited to the lack of documentation for the required treatments and care tasks for the resident during the specified period.
Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
A deficiency was identified during tracheostomy care for a resident with a history of acute respiratory failure with hypoxia, anoxic brain damage, and congestive heart failure, who was in a persistent vegetative state and had a tracheostomy. During observation, the Respiratory Therapist (RT) failed to disinfect the table before placing tracheostomy supplies on it and opened a sterile suction tray while wearing gloves that had already been used. The RT then contaminated the sterile gloves by touching them with the dirty gloves and proceeded to suction the resident. After suctioning, the RT did not remove the inner pair of gloves or sanitize hands before donning a new pair of clean gloves, and continued to handle sterile supplies and perform care without proper hand hygiene or glove changes as required by facility policy. Interviews with the RT and the Director of Nursing confirmed that the RT did not follow infection control protocols, including failing to disinfect surfaces, contaminating sterile gloves, and not performing hand hygiene between glove changes. Review of the facility's tracheostomy care policy indicated that gloves should be changed and hands sanitized at specific steps, which was not followed during the observed care. These actions and inactions led to a failure to adhere to infection prevention and control guidelines during tracheostomy care for the resident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Thoroughly Investigate Narcotic Medication Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of narcotic medication misappropriation after multiple controlled medication discrepancies were identified involving a registered nurse. The facility's own documentation showed that controlled medications were signed out in the control log but not documented in the Medication Administration Record (MAR) for 17 residents. Despite this, only a portion of the affected residents were assessed for pain outcomes, and there was a lack of documented follow-up pain evaluations for 9 out of 14 residents listed in the facility's self-reported incident. Interviews with facility leadership revealed that the investigation into the medication discrepancies was incomplete, as not all affected residents were interviewed or had their pain outcomes evaluated and documented. The Director of Nursing stated that both verbal and written pain evaluations were conducted, but not all were documented. No evidence was provided to show that all residents potentially impacted by the medication discrepancies were properly assessed, resulting in an incomplete investigation of the alleged violation.
Delayed Reporting of Suspected Medication Diversion
Penalty
Summary
The facility failed to submit a Facility Reported Incident regarding a possible diversion of narcotic medications to the State Survey Agency within the required timeframe. On 05/30/2025, the facility became aware of multiple controlled medication errors and identified a registered nurse as responsible for the discrepancies. Despite this, the incident was not reported to the State Survey Agency until 06/02/2025. During an interview, the Nursing Home Administrator stated that corporate advised against immediate reporting while the facility continued its internal investigation to determine if misappropriation had occurred, resulting in a delayed report beyond the mandated period.
Lack of Registered Dietician Oversight in Nutritional Assessments
Penalty
Summary
The facility failed to ensure that the Dietary Technician (DT) received appropriate oversight and supervision from the Registered Dietician (RD) in the assessment and ongoing nutritional care of two residents. According to the 2024 Scope and Standards of Practice for Nutrition and Dietetics Technician, Registered, NDTRs must work under the clinical supervision of an RDN when engaged in direct patient nutrition activities, and the RDN is responsible for completing nutritional assessments and supervising technical staff. However, documentation for both residents showed that the DT completed nutritional assessments and progress notes without evidence of RD review or consultation, even in high-risk cases. One resident was admitted with multiple pressure ulcers and diabetes, and experienced significant weight loss over a 90-day period. The DT documented all aspects of the nutritional assessment and progress notes, including diet orders, weight trends, and interventions, but there was no indication that the RD had reviewed or participated in these assessments. The DT also signed progress notes as the dietician, and during interviews, described managing the resident’s nutritional care independently, including offering supplements and adjusting menus based on preferences and intake, without documented RD involvement. Another resident was admitted after a recent stroke with difficulty swallowing and experienced a notable weight loss within one week of admission. The DT again completed the nutritional assessment and implemented interventions such as fortified foods and weekly weights, but there was no documentation of RD oversight or consultation. Interviews with the RD revealed that she relied on the DT to alert her to high-risk cases and did not routinely review or sign off on assessments or attend relevant meetings. The RD was unaware of the specific high-risk cases and the DT’s practice of signing notes as the dietician.
Inaccurate MDS Coding for Weight and Wound Count
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one resident. Specifically, the quarterly assessment recorded the resident's weight as 155 pounds, which was the admission weight, instead of the correct weight of 141 pounds documented seven days prior to the assessment. Additionally, the discharge return anticipated assessment inaccurately documented the number of unstageable wounds as five, while the wound care provider's note indicated there were only four unstageable wounds present at that time. These inaccuracies were confirmed by the MDS Coordinator, who acknowledged the errors in both the weight and wound count coding. The resident involved had a history of peripheral vascular disease, stroke, and diabetes, and was cognitively intact at the time of the assessments. The facility's policy and the RAI manual require accurate and validated assessments, but these requirements were not met in this instance.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide showers as scheduled for two residents who were dependent on staff for activities of daily living, specifically bathing. For one resident with spina bifida, paraplegia, and a urostomy, care plans and physician orders required substantial staff assistance for scheduled showers and documentation of refusals. However, documentation revealed missed showers, lack of proper recording of refusals, and incomplete follow-through on required documentation in both the electronic medical record and on shower sheets. Interviews with staff confirmed that the resident was not consistently offered showers as scheduled, and that refusals were not always documented or reported according to facility policy. For another resident with peripheral vascular disease and multiple wounds, care plans and orders also required total staff assistance for bathing and documentation of refusals. Review of records showed inconsistent documentation of showers and refusals, with several instances where shower sheets were not signed by a nurse and no corresponding nursing progress notes explaining the refusals. Staff interviews indicated that the process for documenting refusals and ensuring nurse follow-up was not consistently followed, and that some showers or bed baths may not have been offered or properly recorded. Facility policy required that all showers or refusals be documented, including the reason for refusal, interventions taken, and nurse sign-off. The lack of consistent documentation and failure to follow established procedures for offering and recording showers and refusals resulted in these two residents not receiving scheduled showers or appropriate documentation, placing them at risk for skin breakdown and diminished quality of life.
Lack of RD Oversight in Nutritional Management
Penalty
Summary
The facility failed to ensure proper oversight and supervision by the Registered Dietician (RD) of the Dietary Technician (DT) for a resident who was at increased risk for unintended weight loss. The resident, who had a history of stroke with left side paralysis, difficulty swallowing, and dementia, was admitted with severe cognitive impairment and total dependence for feeding. The care plan identified the need for a mechanically modified diet, assistance with meals, and supervision due to pocketing food. Despite these interventions, the resident's oral intake remained less than 50%, and she refused oral nutritional supplements, with fortified foods being added as an alternative. The resident experienced a significant weight loss of 6.7 pounds in one week. Observations revealed that the resident was often left without staff assistance at mealtimes, resulting in minimal food consumption. Interviews with staff indicated that the DT, rather than the RD, completed the admission nutritional assessment and made changes to the resident's care plan without the RD's awareness. The RD confirmed she was not informed about the resident's high-risk status or the weight loss, and that she typically reviews high-risk assessments with the DT but was not involved in this case. This lack of RD oversight and communication contributed to the failure to maintain the resident's nutritional status.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to implement enhanced barrier precautions (EBP) during wound care for one resident with venous stasis ulcers. During an observed wound care procedure, a registered nurse and a wound technician did not wear gowns as required by facility policy, despite gowns being readily available in the room and signage indicating that EBP was necessary. The staff performed hand hygiene and wore gloves, but omitted the use of gowns. The physician present confirmed the wounds were venous stasis ulcers, which are considered chronic wounds under the facility's EBP policy. When questioned, the registered nurse stated that she believed gowns were only required if the wound was draining, not during all wound care. The unit manager clarified that staff had been in-serviced on EBP and that the policy requires the use of gowns for all wound care involving chronic wounds, regardless of drainage. The failure to follow the established EBP protocol was identified through observation, interview, and review of facility policy and records.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a Certified Nurse Aide (CNA). The incident involved CNA D intentionally moving the resident's call light out of reach and closing the door, which deprived the resident of the ability to summon assistance. This action was reported by CNA D to RN E, but RN E did not report the incident to the Nursing Home Administrator (NHA), allowing CNA D to continue working for three additional shifts before being suspended. The resident involved was readmitted to the facility with diagnoses including traumatic spinal cord dysfunction and quadriplegia, making them dependent on staff for all activities of daily living. The resident's care plan emphasized the importance of having the call light within reach. Despite this, CNA D removed the call light after an argument with the resident, leaving them in the dark and unable to communicate their needs. The resident reported feeling better and safer after the call light was returned by RN E. The facility's policies required immediate reporting of abuse allegations to the Administrator and other appropriate agencies, but RN E failed to do so, believing the situation was handled. This oversight allowed CNA D to remain in the facility, posing a potential risk to the resident. The failure to report and address the abuse promptly led to a finding of immediate jeopardy, highlighting a significant deficiency in the facility's handling of abuse allegations.
Removal Plan
- RN E was given a verbal education on abuse policy, reporting compliance, and to always contact the Administrator if there are any allegations of abuse.
- CNA D was removed from resident care prior to the start of shift.
- All nursing staff will be re-educated on abuse, neglect and misappropriation policy education; abuse reporting and compliance policy; resident call light accessibility.
- Administrator or designee to orient all new staff on the abuse reporting policy and how to contact those individuals.
- Director of Nursing or designee to provide education on abuse reporting policy monthly at staff meetings.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse immediately to the Administrator, as required by their policy. This failure placed all residents at risk because the accused staff member, CNA D, was allowed to continue working with residents for three additional shifts before the incident was reported to the administration. The incident involved CNA D refusing to provide care to a resident, R1, who has a traumatic spinal cord dysfunction and quadriplegia, and is dependent on staff for all activities of daily living. CNA D removed R1's puff-activated call light and shut the resident's door, actions which were reported to RN E but not escalated further. RN E, upon learning of the incident, instructed CNA D not to return to R1's room and returned the call light to R1. However, RN E did not report the incident to the Nursing Home Administrator or any other authority, believing she had handled the situation. As a result, the incident was not reported to the State Survey Agency until several days later, and an investigation did not begin until after this delay. The facility's policy mandates that such allegations be reported immediately, but this protocol was not followed, leading to a significant delay in addressing the situation.
Unlicensed Staff Administering Medications
Penalty
Summary
The facility failed to ensure that only licensed nursing staff administered medications to residents on the Heritage unit, which led to a deficiency. The facility's policy on medication administration, revised in May 2022, states that medications should be administered by licensed nurses or other legally authorized staff. However, during a holiday when several nurses called in sick, the Director of Nursing (DON) instructed Certified Nursing Aides (CNAs) to pass medications to residents, a task outside their scope of practice. Interviews with staff revealed that CNAs were asked to participate in a practice referred to as 'push and pass,' where a Registered Nurse (RN) would dispense medications into a cup, and the CNA would then deliver the medications to the residents. This occurred under the direct supervision of the RN, who maintained line of sight. Despite this supervision, the practice was not in compliance with state regulations, which only allow CNAs with specific medication aide training and designation to pass medications. The Nursing Home Administrator (NHA) was aware of the situation and deferred to the DON's decision to allow CNAs to pass medications. The DON justified the decision by citing the absence of nurses and the need to ensure timely medication administration. However, this action was outside the permissible delegation scope, as confirmed by the Pharmacy Practice Consultant with the Department of Health Services, who outlined the specific conditions under which CNAs could administer medications.
Verbal Abuse by Staff Members
Penalty
Summary
The facility failed to protect three residents from verbal abuse by two staff members, which placed them at risk of psychosocial harm. The first incident involved a CNA who was verbally abusive to two residents during mealtime. One resident, who was severely cognitively impaired, was threatened by the CNA for not eating properly, while another resident, who was cognitively intact, was forced to eat and ridiculed for her eating habits, causing her to cry. A fellow CNA witnessed the abuse but did not intervene directly, instead reporting it to the nurse and the Nursing Home Administrator. In a separate incident, another CNA made racially insensitive remarks while providing ostomy care to a resident. The resident, who was cognitively intact, did not recall the specific comments but remembered the CNA's frustration during the care process. An LPN present during the incident reported the remarks to the Nursing Home Administrator, leading to the CNA being placed on administrative leave. The Director of Nursing noted that the CNA involved in the first incident was a new employee, while the CNA in the second incident resigned after being placed on leave. The Nursing Home Administrator confirmed that verbal abuse was substantiated in both cases, highlighting a failure in the facility's policy to prevent and prohibit abuse, neglect, and exploitation of residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near South Milwaukee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowcrest Health Services | 0.2 mi | — | 0 | 0 |
| Medical Suites At Oak Creek (the) | 4.4 mi | — | 22 | 0 |
| Maple Ridge Health Services | 5.2 mi | — | 0 | 0 |
| Autumn Lake Healthcare At Greenfield | 5.2 mi | — | 5 | 1 |
| St Francis Health Services | 5.5 mi | — | 13 | 0 |
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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.