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 Franciscan Woods during CMS and state inspections, most recent first.
A resident with diabetes and multiple comorbidities developed unstageable bilateral heel pressure injuries due to the facility's failure to perform and document daily foot checks, lack of person-centered interventions for turning and repositioning, delayed comprehensive skin assessments after hospital readmission, and delayed implementation of wound care orders. Staff interviews revealed confusion about wound care responsibilities and a lack of timely updates to the care plan and treatment records.
An LPN was observed using a ballpoint pen to stab open bubble packs for medication administration to two residents, affecting 20 out of 32 opportunities and resulting in a medication error rate of 62.5%. The improper technique was witnessed during the administration of multiple medications, and one resident voiced concern about their medications being crushed. The DON was informed of these findings.
A resident with a history of care refusal and physical aggression became upset when a CNA did not comply with her request for pull-ups instead of a brief. Instead of following care plan interventions such as walking away or seeking assistance, the CNA held the resident's wrists to prevent being hit, resulting in a bruise and emotional distress. The incident demonstrated a failure to follow abuse prevention protocols and resident-specific care approaches.
Three residents experienced injuries or pain due to staff not following care plans requiring two-person assistance for bed mobility and transfers, and not using proper equipment or techniques. In each case, staff acted alone or used improper methods, resulting in falls, bruising, or pain, and the facility could not provide documentation that required staff re-education or therapy evaluations were completed.
A resident with multiple medical conditions did not receive prescribed doses of Ingrezza for Tardive Dyskinesia on several occasions, including a period when the dose was increased and the correct medication was not obtained from the pharmacy. Nursing staff did not document reasons for missed doses or notify the physician or medical director, and challenges with agency nurses contributed to inadequate charting and follow-up.
A resident with a history of pulmonary embolism and on Eliquis for DVT prophylaxis was not monitored for signs of bleeding as required by facility policy and the care plan. Review of medical records showed no evidence of daily monitoring for complications, and staff could not provide documentation or a standard practice for the claimed charting by exception.
Surveyors found that the facility failed to ensure timely and comprehensive assessment, treatment, and care planning for pressure injuries in three residents. In each case, there were delays in RN assessment, late or missing care plan updates, and lapses in wound care documentation and intervention, resulting in the progression of wounds and inadequate prevention of new ulcers.
A resident with multiple comorbidities and severe cognitive impairment experienced unplanned, severe weight loss over six months, during which no new nutritional interventions were implemented and the care plan was not updated. Despite clear evidence of weight decline and the development of pressure injuries, the registered dietitian documented the weight as stable, and there was a lack of communication with the resident's POA and physician. Incomplete meal intake records and failure to integrate hospice dietary recommendations further contributed to the deficiency.
The facility did not document the investigation or control measures for an influenza A outbreak affecting multiple residents, and failed to track infection organisms in its surveillance logs as required by policy. The Infection Preventionist maintained only a line list for the outbreak and did not provide an investigative summary or track all infection organisms, leading to incomplete infection surveillance and documentation.
The facility did not follow its abuse investigation and reporting policies after multiple residents experienced or reported concerning interactions with CNAs, including verbal remarks, lack of care, and disregard for preferences. Incidents were not thoroughly investigated or reported to the DON or state agency, and required documentation and communication steps were not completed.
Multiple allegations of abuse, neglect, and mistreatment involving several residents were not thoroughly investigated by facility staff. In one instance, a resident reported being physically mistreated by a CNA, but not all potentially involved residents were interviewed. Another resident with severe cognitive impairment had unexplained injuries, yet not all staff were interviewed and no root cause was documented. Additional complaints about care and staff conduct were handled informally, with no evidence of formal investigation or required reporting. The facility did not follow its own policies for investigating and documenting alleged violations.
The facility did not document thorough investigations or provide written resolutions for grievances filed by three residents, including concerns about staff interactions and care requests. In each case, required steps such as documenting investigative actions, interviews, and issuing final written decisions were not completed, contrary to facility policy.
The facility did not report multiple allegations of abuse and neglect involving three residents to the Administrator or State Survey Agency as required. Incidents included delayed care, inappropriate staff comments, a resident left without proper clothing for hours, and a resident not receiving care due to refusal of a male caregiver. Leadership was unaware of these events and did not initiate required investigations or notifications.
A resident was provided with bilateral bed mobility devices at the request of their family, but the facility failed to complete a comprehensive assessment prior to installation. Although a consent form was signed and maintenance installed the devices, documentation showed no device was needed, and the care plan and physician orders did not address the devices. Staff interviews confirmed the absence of a required assessment.
A resident with significant medical needs was admitted with a newly discovered pressure injury, but did not receive timely wound treatment or pressure-relieving interventions. The physician was not notified, and no care was documented for two days, during which the wound worsened. Staff interviews confirmed that expected protocols for pressure injury management were not followed.
Three residents with skin integrity issues did not receive timely assessments, monitoring, or documentation as required by facility policy and care plans. One resident was not assessed with a Braden Scale or comprehensive skin assessment upon readmission, another had a skin tear that was not treated or monitored for a week, leading to infection, and a third resident's new skin tear after a fall was not documented or monitored as ordered. Staff interviews confirmed lapses in following established procedures.
A resident on long-term anticoagulant therapy did not receive timely PT/INR testing as ordered, leading to continued administration of warfarin despite elevated levels. The facility's failure to adhere to procedures for monitoring anticoagulant therapy was acknowledged by the DON, but no further explanation was provided.
A resident did not receive the antibiotic Ceftin as prescribed in the hospital discharge summary due to the facility's failure to transcribe the order. Despite the discharge summary clearly indicating the need for continuation of the antibiotic, the Director of Nursing and staff did not thoroughly review the document, leading to the omission. The resident's POA raised concerns, but the facility did not contact the physician to clarify the order.
A resident with a gastrostomy tube was not provided with the prescribed Osmolite 1.2 tube feeding formula, as the facility administered Jevity 1.2 instead. Additionally, medications were not properly crushed, leading to a clogged feeding tube and subsequent hospitalization. The facility's lack of communication and follow-up contributed to the deficiency.
The facility failed to provide adequate staffing, resulting in delayed care for residents, including insufficient toileting, bathing, and hygiene. Residents experienced long waits for assistance, and agency staff were often unfamiliar with residents' needs. Family members and staff reported concerns about staffing levels, particularly on weekends.
A dietary aide failed to adhere to proper glove use and hand hygiene during meal service, leading to potential cross-contamination. The aide was observed repositioning food and touching various items without changing gloves or washing hands, contrary to the facility's policy. The Dietary Manager confirmed the improper practice and acknowledged the risk of cross-contamination.
The facility failed to ensure appropriate PPE use for two residents requiring enhanced barrier precautions during wound care, as staff did not wear gowns. Additionally, patient care equipment was not cleaned between uses for three residents, increasing the risk of MDRO spread. The Infection Preventionist and DON acknowledged the oversight, and the facility's policies on EBP and equipment cleaning were not consistently followed.
A resident's Responsible Party (RP) reported that staff failed to change the resident's incontinence brief regularly, leaving the resident frequently saturated with urine. Despite the RP's email to the unit manager being considered a formal grievance, the facility did not log or address it. The Social Service Director and Administrator confirmed the grievance was not entered into the grievance process.
A facility failed to provide a written transfer notice to a resident and their responsible party when the resident was transferred to the hospital. The resident, who was cognitively intact, did not recall receiving the notice. The facility's administrator confirmed that written notices were not being provided, contrary to the facility's policy.
A resident with dementia and anxiety was prescribed PRN Ativan without a stop date, contrary to the facility's policy requiring such orders to have a specified duration. The resident received the medication multiple times, and staff interviews confirmed the oversight, with the DON acknowledging the need for a stop date.
A facility failed to notify a resident's responsible party of significant changes in the resident's condition, including a new pressure injury and purple marks. Despite the facility's policy, there was no documentation of notification, and interviews confirmed the responsible party was unaware of these changes.
Two residents in a facility did not receive adequate assistance with activities of daily living, leading to hygiene deficiencies. One resident, with Alzheimer's, experienced inconsistent showering and was often left saturated with urine. Another resident, dependent on staff for all care, went over six weeks without a documented shower, with family members reporting soiled conditions. Staffing inconsistencies and lack of adherence to care plans contributed to these issues.
The facility did not post or maintain nurse staffing information as required. The nurse staffing information lacked the resident census and was not posted daily. The DON confirmed the omission, and the new Staffing Coordinator was unaware of the posting requirement until recently. Records prior to 10/20/24 were unavailable.
The facility failed to document ADLs, meal intake, and scheduled treatments for several residents, including those with severe cognitive impairment, quadriplegia, and chronic ulcers. Staff interviews revealed inconsistencies in documentation practices, and the Director of Nursing acknowledged ongoing issues with record-keeping.
Failure to Prevent and Timely Treat Pressure Injuries in High-Risk Resident
Penalty
Summary
A resident with multiple comorbidities, including diabetes, peripheral vascular disease, chronic kidney disease, and hemiplegia, was admitted to the facility and assessed as being at risk for pressure injuries. The resident's care plan included interventions such as daily diabetic foot checks and pressure injury prevention measures, but there was no documentation that these interventions were consistently implemented. Specifically, daily foot checks were not documented, and person-centered interventions for turning and repositioning were not included in the care plan, despite the resident being dependent on staff for activities of daily living. On one occasion, the resident's family notified facility staff of bilateral heel pressure injuries. The facility documented the left heel injury but failed to assess or document the right heel injury prior to the resident's transfer to the hospital. Upon return from the hospital, a comprehensive skin assessment was not completed until two days later, and wound care treatment orders were not implemented until four days after the resident's return. The care plan was not updated to reflect the new pressure injuries until several days after their discovery, and orders for wound care did not carry over to the Medication Administration Record (MAR) or Treatment Administration Record (TAR), resulting in a lack of evidence that wound care was provided as ordered. Interviews with facility staff revealed confusion regarding responsibility for wound care and skin assessments, with the Director of Nursing and Nursing Home Administrator unable to identify who was performing wound care rounds. Staff acknowledged that standard practices, such as comprehensive skin assessments upon readmission and timely implementation of wound care orders, were not followed. The resident was not followed by podiatry for circulatory concerns during their stay, despite recommendations in the medical record. These failures resulted in the resident developing unstageable, facility-acquired bilateral heel pressure injuries that worsened over time.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Bubble Pack Opening
Penalty
Summary
The facility failed to ensure that the medication error rate during medication administration was below 5%. During a medication pass observed by the surveyor, an LPN was seen using a ballpoint pen to stab open bubble packs containing medications for two residents. This method was used for a total of 20 out of 32 medication administration opportunities, resulting in a medication error rate of 62.5%. The LPN laid out the bubble packs on the medication cart, exposed the pen tip, and punctured each pack to dispense the tablets into a medication cup before administering them to the residents. One resident received eight different medications, including Amlodipine, Certravite, Folic Acid, Hydrochlorothiazide, Turmeric, Vitamin B complex, Thiamine, and Vitamin C. Another resident received twelve medications, including Tamsulosin, Losartan, Memantine, Metoprolol ER, Thiamine, Vitamin K with D3, Aspirin, Chlorthalidone, CoQ10, Folic Acid, Gabapentin, and Glimepiride. The improper method of opening the bubble packs was observed by the surveyor, and one resident expressed concern about their medications being crushed, which the LPN denied. The Director of Nursing was notified of the surveyor's findings and acknowledged the concerns.
Failure to Prevent Physical Abuse During Resident Care
Penalty
Summary
The facility failed to prevent physical abuse of a resident who was cognitively intact and had a history of refusing care and being physically aggressive with staff. The resident's care plan directed staff to educate her about care options, give her time and space if she was resistive, and re-approach in a calm manner. On the day of the incident, a CNA did not follow these approaches when the resident became upset about being given a brief instead of pull-ups. Instead of walking away, seeking assistance, or complying with the resident's request, the CNA held the resident's wrists to prevent her from hitting, resulting in a 4 cm bruise to the resident's left wrist and emotional distress. Interviews and documentation confirmed that the resident was upset after the incident, reporting bruises on both wrists and expressing emotional upset. The CNA involved stated she was trying to prevent being hit, but did not follow the facility's protocols for managing agitated or combative residents. The facility's abuse prevention policy prohibits physical abuse and requires staff to use non-restrictive interventions. The incident was reported, investigated, and the CNA was terminated, but the deficiency centers on the failure to prevent physical abuse and follow established care protocols.
Failure to Follow Care Plans and Provide Adequate Supervision Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure that staff followed resident care plans and provided adequate supervision and assistance to prevent accidents for three residents. In multiple instances, staff did not adhere to the required two-person assist for bed mobility and transfers, as documented in the residents' care plans. For one resident with severe cognitive impairment and total dependence on staff for bed mobility, two separate falls occurred during care when only one staff member was present, resulting in injuries that required emergency room evaluation. Staff involved in these incidents acknowledged they were aware of the two-person assist requirement but did not follow it. Another resident, who required extensive two-person assistance with a gait belt for transfers due to physical impairments and moderate fall risk, reported being transferred by a single CNA who lifted the resident by the biceps without a gait belt. This action was not in accordance with the resident's care plan and caused the resident pain. The facility's own investigation confirmed that the care plan was not followed during this transfer. A third resident, dependent on staff for all mobility and transfers and requiring a mechanical lift, was found with a large bruise on the upper extremity. The facility determined the injury likely occurred when staff improperly grabbed the resident's arm to assist with rolling in bed or due to poor positioning in a wheelchair. The required evaluation by physical therapy for wheelchair positioning was not completed, and staff did not receive documented re-education on proper handling techniques as indicated in the facility's incident report. In all cases, the facility was unable to provide documentation that staff re-education or corrective interventions were completed as required by their own policies.
Failure to Provide Ordered Medication and Ensure Pharmaceutical Services
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services to ensure that a resident received their prescribed medication, Ingrezza (Valbenazine), as ordered by their physician. The resident, who had diagnoses including congestive heart failure, morbid obesity, drug-induced subacute dyskinesia, and major depressive disorder, was admitted with an order for Ingrezza 40 mg daily for Tardive Dyskinesia. The medication was not administered on one occasion and then missed for a consecutive twelve-day period, totaling thirteen missed doses. There was no documentation in the resident's medical record explaining why the medication was not given, nor any evidence that the pharmacy or physician was notified during these missed doses. Further issues arose when the resident's Ingrezza dose was increased to 60 mg daily. The facility was unable to obtain the correct dose from the pharmacy, and the resident continued to receive the lower 40 mg dose for several days. Nursing notes indicated attempts to contact the pharmacy and the physician, but the correct dose was not provided, and the resident did not receive the ordered medication as prescribed. There was also a lack of documentation regarding physician notification or involvement of the medical director when the facility could not resolve the medication issue. Interviews with nursing staff revealed that the facility was experiencing challenges with agency nurses and charting, which contributed to the lack of documentation and follow-up. The staff confirmed that the resident did not receive the correct dose of Ingrezza and that there was no escalation to the medical director when the physician could not be reached. These actions and inactions resulted in the resident not receiving their medication as ordered, with insufficient documentation and communication regarding the missed doses.
Failure to Monitor for Adverse Reactions to Anticoagulant Medication
Penalty
Summary
The facility failed to ensure appropriate monitoring for adverse reactions to a high-risk medication for one resident receiving Eliquis, an anticoagulant prescribed for deep vein thrombosis prophylaxis. The resident had a history of pulmonary embolism and long-term anticoagulant use. Facility policy required monitoring for possible complications in individuals on anticoagulants, and the resident's care plan specifically directed staff to monitor daily for signs of active bleeding, such as hematuria, petechiae, bruising, bloody stools, or nosebleeds. Upon review of the resident's medical record, including progress notes, medication administration records, and treatment administration records, the surveyor was unable to find evidence that monitoring for complications from Eliquis was being performed. When questioned, nursing staff and management were unable to provide documentation or a standard practice supporting their claim of charting by exception for this monitoring. The lack of documented monitoring was confirmed by both the RN and the DON during the survey.
Failure to Provide Timely and Comprehensive Pressure Ulcer Care
Penalty
Summary
Surveyors identified that the facility failed to provide necessary treatment and services consistent with professional standards of practice for residents with pressure injuries, resulting in delayed assessments, lack of timely interventions, and inadequate care planning. In one case, a resident with multiple comorbidities, including severe cognitive impairment, diabetes, and malnutrition, developed a deep tissue injury (DTI) on the heel that was not assessed by a Registered Nurse (RN) until eight days after discovery. The care plan was not promptly updated, and there was a delay in implementing interventions such as Prevalon boots. The DTI subsequently progressed to a stage 3 pressure injury. Additionally, there was no evidence of nutritional interventions being attempted despite significant weight loss and malnutrition, and the care plan updates lagged behind the resident's changing condition. Another resident developed a stage 2 pressure injury to the left buttocks, which was identified by a Certified Nursing Assistant (CNA) during a bath. However, a comprehensive assessment was not performed until three days later, and treatment orders were not obtained until that time. The care plan was also not updated until three days after the wound was found. Documentation revealed that wound care was not performed on at least one occasion, and the resident declined care on another, resulting in two consecutive days without wound care treatment. Interviews with staff indicated confusion regarding the process and timeframe for comprehensive assessment and care plan updates following the identification of new pressure injuries. A third resident developed a new wound on the mid-back, which was not comprehensively assessed until four days after discovery, and the care plan was not updated with new interventions until that time. Documentation of wound care was also missing for at least one day. Across all cases, surveyors noted delays in RN assessments, inconsistent or delayed care plan updates, and lapses in documentation and implementation of wound care interventions. These deficiencies were observed through record review, staff interviews, and direct observation, and were not corrected upon revisit.
Failure to Prevent and Address Severe Weight Loss in a Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, resulting in severe, unplanned weight loss over a six-month period. The resident, who had diagnoses including type 2 diabetes, heart failure, cognitive impairment, and vascular dementia, was totally dependent on staff for eating and drinking and required a mechanically altered diet. Despite a significant and progressive decline in weight, no new nutritional interventions were implemented, and the care plan was not updated to address the weight loss. The facility's own policies required reassessment and care plan updates in response to significant weight changes, but these actions were not taken. Documentation revealed that the resident's weight dropped from 131.0 pounds to 107.0 pounds over six months, representing an 18.32% loss. The registered dietitian repeatedly documented the resident's weight as stable in assessments, despite clear evidence of ongoing weight loss. There was also a lack of communication with the resident's power of attorney and physician regarding the weight loss, as required by facility policy. Intake records were incomplete, with many meals not documented, making it unclear whether the resident was consistently offered or assisted with meals as needed. During this period of weight loss, the resident developed pressure injuries, and there was no evidence of additional nutritional interventions or reassessment following the onset of these wounds. Interviews with staff confirmed that no new interventions were attempted, and the hospice plan of care was not integrated into the facility's care plan. The facility did not provide evidence that the resident's nutritional needs were reassessed or that efforts were made to identify foods the resident might prefer or be more likely to consume. The deficiency was further compounded by inconsistent documentation and a lack of follow-through on required monitoring and communication.
Failure to Document Investigation and Control of Influenza A Outbreak
Penalty
Summary
The facility failed to document the investigation and control of an influenza A outbreak that occurred in February 2025, as required by its own infection prevention and control policies. Although a line list of 14 residents affected by influenza A on the 3rd floor was maintained, there was no investigative summary or documentation outlining the steps taken to identify, prevent, and control the spread of the infection. The Infection Preventionist (IP) confirmed that only a line list was available and no further documentation regarding the outbreak investigation existed. Additionally, the IP stated that infection organisms were not routinely tracked unless they were reportable or classified as multidrug-resistant organisms (MDROs), which is inconsistent with the facility's policy requiring surveillance and documentation of all infection organisms. Surveillance logs for January, February, and March 2025 did not include the specific organisms related to infections, except for the influenza A line list. The IP was unable to provide a reason for the lack of documentation and did not track all organisms causing infections in the facility. The deficiency was identified during interviews and record reviews, where it was also noted that the facility's policies require prompt identification, investigation, and documentation of outbreaks, as well as ongoing surveillance of infection organisms, which was not followed in this instance.
Failure to Implement Abuse Investigation and Reporting Policies
Penalty
Summary
The facility failed to implement its written policies and procedures for investigating and reporting allegations of abuse, neglect, and mistreatment. In three reviewed cases, residents reported or experienced concerning interactions with CNAs, including verbal remarks, lack of timely care, and disregard for resident preferences. For example, one resident was told by a CNA to go to bed and stop looking at the clock, and was discouraged from expressing discomfort during care. Another resident reported being left in bed in only a brief for five hours after a CNA threw their clothing and blankets across the room and told them not to call again. A third resident did not receive care during a male CNA's shift because the resident did not want a male caregiver, and the CNA failed to inform anyone or ensure the resident's needs were met. Despite these incidents being documented in the facility's grievance log and discussed among staff, there was no evidence of a comprehensive, documented investigation as required by facility policy. The policies mandate prompt reporting to the administrator and state agencies, thorough investigation steps including interviews and written witness statements, and keeping residents and their representatives informed. However, interviews with the DON, NHA, and unit manager revealed a lack of awareness of the full scope of the incidents, incomplete documentation, and no formal Facility Reported Incidents (FRIs) submitted for the cases in question. The facility's failure to follow its own abuse investigation and reporting procedures resulted in allegations not being thoroughly investigated or reported to the appropriate authorities. Staff involved did not recognize certain incidents as reportable abuse or neglect, and there was no evidence of corrective action or communication with residents and families as outlined in policy. This deficiency had the potential to affect all residents in the facility.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse, neglect, and mistreatment for five residents, as required by its own policies and federal regulations. In one case, a cognitively intact resident alleged that a CNA caused bruising by slamming her legs into a bed frame and made her wait over an hour for assistance. The facility's investigation did not include interviews with all residents who may have been cared for by the CNA on the relevant shifts, nor did it interview residents on other units where the CNA worked during the period in question. The Director of Nursing acknowledged that the investigation was incomplete after being informed by the surveyor. Another resident with severe cognitive impairment had multiple injuries of unknown origin, including bruises and skin tears, which were reported as possible abuse by the resident's Power of Attorney. The facility's investigation did not include interviews with all staff who worked with the resident on the sampled dates, and there was no documentation of a root cause analysis or interventions to prevent recurrence. The documentation provided was limited to staff and resident interviews and entries in the Safety Event Manager, with no evidence of monitoring or follow-up as stated in the facility's own records. Additional deficiencies were identified in the handling of concerns raised by or on behalf of three other residents. In two cases, complaints about the conduct and care provided by a float pool CNA were documented only in email correspondence, with no evidence of a formal investigation or reporting as required. In another case, a resident's family reported care concerns, but there was no detailed documentation or investigation, and the only action taken was re-education of the CNA involved. Across all cases, the facility failed to follow its policy for thorough investigation, documentation, and reporting of alleged violations involving abuse, neglect, or mistreatment.
Failure to Document and Resolve Resident Grievances per Facility Policy
Penalty
Summary
The facility failed to document thorough investigations and resolutions of resident grievances as required by its own policy for three of six residents reviewed. In the case of one resident, who was admitted for rehabilitation after surgery and had intact cognition, a grievance was filed regarding staff not checking on her for hours. Although the nurse manager reported speaking with staff and the resident, there was no documentation of the investigative steps taken, interviews conducted, or a final written grievance decision provided to the resident, as required by facility policy. Another resident filed a grievance about a negative interaction with a CNA. The facility's grievance log noted that the CNA was removed from the resident's assignment and that the resident later denied further concerns. However, there was no comprehensive documentation of the investigation process, including details of the interaction, interviews with involved parties, or a written resolution. Staff interviews confirmed that no written documentation of the investigation or resolution was completed. A third resident reported being denied a request to be double briefed by a CNA. The grievance log indicated that the resident was informed why double briefing was not possible and that the concern was resolved. However, there was no documentation of the investigative process, interviews, or a written resolution. The facility staff, including the social worker, unit manager, and DON, were unable to provide any documentation related to the investigation or resolution of this grievance. In all three cases, the facility did not follow its policy for documenting and resolving grievances.
Failure to Report Alleged Abuse and Neglect to Authorities
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, or mistreatment were reported to the Nursing Home Administrator and the State Survey Agency as required by policy and regulation. In three separate cases, residents reported or experienced concerning interactions with a Certified Nursing Assistant (CNA), but these incidents were not properly documented, investigated, or reported to the appropriate authorities. The facility's own policies require prompt reporting and thorough investigation of all such allegations, but this process was not followed. One resident reported that after requesting to be changed, the CNA delayed care, made inappropriate comments about the resident's age and learning ability, and discouraged the resident from expressing discomfort during care. Another resident described a situation where a CNA left them in bed in only a brief for five hours after throwing their blankets and clothing across the room, and told the resident not to call again. In both cases, there was no evidence that these concerns were reported to the Administrator or the State Survey Agency, and no documentation of a formal investigation was provided. A third resident's family expressed concerns after the resident did not want care from a male caregiver, and as a result, did not receive care for an entire shift. The male CNA did not inform anyone of the resident's refusal, and the incident was not reported to the State Survey Agency. Interviews with facility leadership revealed a lack of awareness of these incidents and a misunderstanding of what constitutes a reportable event, resulting in a failure to follow required reporting procedures.
Failure to Complete Comprehensive Assessment Before Applying Bed Mobility Devices
Penalty
Summary
A deficiency was identified when a resident was observed with bilateral bed mobility devices installed without a comprehensive assessment as required by facility policy. The resident had been readmitted from the hospital, was alert and oriented, and the family requested bed railings. Maintenance installed the bed rails following the family's request, but the Device Evaluation form completed after installation indicated that no device was needed. The resident signed a consent form for assistive devices, but this form was a check-box style and did not reflect a thorough assessment process. The resident's care plan did not mention the use of bed mobility devices, and there was no physician order for their use. Interviews with facility staff, including the DON and the unit manager, revealed that the bed rails were applied based on the family's request and not as a result of a documented comprehensive assessment. The DON was unable to provide documentation of a comprehensive assessment for the use of the bed mobility devices, and the unit manager confirmed that such an assessment had not been completed. The lack of a comprehensive assessment prior to the application of bed mobility devices constituted the deficiency.
Failure to Provide Timely Pressure Ulcer Care and Physician Notification
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including a recent hip fracture, malnutrition, Parkinson's disease, and severe cognitive impairment, was admitted to the facility and a pressure injury was discovered on the left upper heel during the initial skin assessment. Despite this finding, there was no evidence that the resident's physician was notified of the newly discovered pressure injury, and no treatment or pressure-relieving interventions were implemented from the time of admission until two days later. The resident's care plan called for observation of skin integrity and use of pressure-relieving devices, but these interventions were not documented as being put in place during this period. During the gap in care, the resident did not receive any wound treatment, and there was no documentation in the Medication Administration Record or Treatment Administration Record of any interventions for the pressure injury. The wound subsequently increased in size and deteriorated, as confirmed by later assessments. Interviews with nursing staff and management revealed that the expected protocol was to notify the physician and initiate treatment orders immediately upon discovery of a new pressure injury, but this did not occur. Additionally, there was no system in place within the electronic health record to alert management to new pressure injuries, and the wound care nurse was not wound certified and did not review residents daily. The lack of timely notification to the physician, absence of documented interventions, and delay in implementing pressure-relieving measures directly contributed to the worsening of the resident's pressure injury. The deficiency was confirmed through record review, staff interviews, and direct observation, with no additional information provided to explain the delay in care or lack of adherence to professional standards of practice for pressure injury management.
Failure to Assess, Monitor, and Document Skin Integrity and Wound Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and established care plans for three residents with skin integrity issues. For one resident admitted with vascular wounds and a history of chronic venous hypertension, the facility did not complete a comprehensive skin assessment or Braden Scale assessment upon readmission, as required by facility policy. The initial skin assessment was delayed until three days after admission, and no Braden Scale was completed post-readmission, despite the resident's risk factors and cognitive intactness. Another resident developed a skin tear that was identified by a family member, but the facility did not implement treatment, assessment, or monitoring for the wound until a week later. There was no documentation of the wound on the Treatment Administration Record (TAR), and no evidence of ongoing assessment or monitoring for signs of infection. The wound subsequently became infected, necessitating antibiotic therapy, but the lack of timely intervention and documentation was noted by both the surveyor and facility staff during interviews. A third resident sustained a skin tear following a fall, but there was no evidence that the facility was monitoring the wound for signs and symptoms of infection. The care plan was not updated to reflect the new injury, and no new treatment orders were entered into the TAR. Documentation on the follow-up board and shift reports failed to mention the skin tear, despite physician orders to monitor the area. Interviews with staff confirmed that the expected procedures for documentation and monitoring were not followed.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the administration of the anticoagulant warfarin. The resident, who had a history of cerebral infarct and was on long-term anticoagulant therapy, was admitted with orders for a PT/INR test to be conducted on a specific date. However, this test was not performed until several days later, during which time the resident continued to receive warfarin. The delayed PT/INR test revealed an elevated level, indicating that the blood was clotting more slowly than normal. The Director of Nurses acknowledged that the PT/INR test should have been conducted as ordered and that the admitting nurse failed to transcribe the order from the hospital discharge documents. The facility's procedure required appropriate lab testing to monitor anticoagulant therapy, but this was not adhered to in this case. Despite the elevated PT/INR, there was no documentation of bleeding or blood clots in the resident's medical record. The findings were shared with the Nursing Home Administrator and the Director of Nurses, but no additional information was provided to explain the oversight.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R185, who did not receive an antibiotic as indicated on the hospital discharge summary. R185 was admitted to the facility with several diagnoses, including small bowel obstruction and acute kidney injury. Upon discharge from the hospital, the discharge summary explicitly stated that the resident was to continue the antibiotic Ceftin for seven more days. However, the facility did not transcribe this order into the Medication Administration Record, and the resident did not receive the antibiotic during their stay. The Director of Nursing (DON) acknowledged that the facility transcribes orders from the Hospital Discharge Summary and not the After Visit Summary (AVS). Despite the discharge summary clearly indicating the continuation of Ceftin, the DON and nursing staff failed to read the entire document thoroughly, resulting in the omission of the antibiotic order. The resident's Power of Attorney (POA) raised concerns multiple times about the missing antibiotic, but the facility did not contact the physician to clarify the order. This oversight led to the resident not receiving the necessary medication as prescribed by the hospital surgeon.
Failure to Administer Tube Feeding and Medications as Ordered
Penalty
Summary
The facility failed to administer tube feeding to a resident, R185, in accordance with the physician's orders. R185 was admitted with a gastrostomy tube and was prescribed Osmolite 1.2 tube feeding formula at 75 ml per hour. However, the facility administered Jevity 1.2 instead, as Osmolite was not in stock. The Registered Dietitian (RD) confirmed that the physician's order was for Osmolite 1.2, but the facility used Jevity 1.2, which was the house formula. The RD stated that Jevity was generally a better formula due to its fiber content, but acknowledged that the order should have been changed to reflect the actual formula being used. Additionally, the facility failed to ensure that medications administered through the feeding tube were properly crushed, as per the physician's orders. This oversight led to a clogged feeding tube, which required R185 to be hospitalized and undergo a surgical procedure to unclog the tube. The Director of Nursing (DON) confirmed that the pills should have been crushed and acknowledged that the facility was responsible for the clogging of the tube due to the administration of uncrushed pills. The incident was further compounded by the lack of communication and follow-up within the facility. The DON was unaware of the surgeon's report indicating that a pill had not been crushed and was the source of the clog. The DON had not yet interviewed the nursing staff to determine what happened with the administration of the pills. This lack of awareness and communication contributed to the deficiency in providing appropriate care for R185's feeding tube administration.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, resulting in inadequate care for six out of 26 sampled residents. Residents experienced delays in receiving assistance with activities of daily living, such as toileting, incontinence care, and bathing. Some residents were double briefed, and others waited excessively long for call lights to be answered. The use of agency staff, who were reportedly not well-trained or familiar with residents' needs, contributed to these deficiencies. One resident, who was severely impaired in decision-making and required assistance with toileting and bathing, went 14 days between showers on two occasions. Observations noted the resident's hair was greasy and unkempt, and family members reported the resident was often saturated with urine due to infrequent changes of incontinence briefs. Another resident, unimpaired in cognition, reported waiting up to 45 minutes for call lights to be answered and having to sit in soiled briefs during the wait. Observations confirmed a 19-minute wait for assistance, during which no staff were present on the unit. Additional residents, including those receiving hospice care, were found to have unkempt appearances and inadequate hygiene due to insufficient staffing. Family members expressed concerns about the lack of regular staff and the frequent use of agency staff, particularly on weekends. Interviews with staff revealed that the facility often operated with fewer staff than needed, leading to delays in care and unmet needs for residents requiring assistance with transfers and other activities of daily living.
Improper Glove Use and Hand Hygiene by Dietary Staff
Penalty
Summary
The facility failed to ensure proper glove use and hand hygiene by dietary staff during meal service, which created the potential for cross-contamination and the spread of foodborne illness. Observations revealed that a dietary aide (DA1) served meals to residents on the west side of the second floor without adhering to the facility's Disposable Glove Use policy. DA1 was observed repositioning food on plates with gloved hands and touching various items such as paper tray cards, plates, and utensils without changing gloves or performing hand hygiene. This practice was noted during both breakfast and lunch services, where DA1 continued to serve food without changing gloves or washing hands, despite touching ready-to-eat food and other surfaces. During an interview, DA1 admitted that it was her normal practice to serve rolls with gloved hands and did not use tongs for serving bread. The Dietary Manager confirmed that staff should not touch food on the tray line with gloved hands and should use tongs for serving rolls. The manager acknowledged the potential for cross-contamination from the gloves to the food due to DA1's actions. The deficiency was observed during meal services for 15 residents residing on the west side of the second floor, with some residents eating in the dining room and others in their rooms.
Inadequate PPE Use and Equipment Cleaning in LTC Facility
Penalty
Summary
The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) for two residents who required enhanced barrier precautions (EBP) during direct care. One resident, who was severely cognitively impaired, had a pressure ulcer requiring EBP, yet the LPN did not wear a gown during wound care. Another resident, who was cognitively intact and had Alzheimer's disease, also required EBP for wound care, but the LPN assisting the wound care nurse practitioner did not wear a gown. The Infection Preventionist admitted to not providing formal in-services and relied on verbal reminders, while the Director of Nursing acknowledged the oversight in identifying the need for EBP. The facility also failed to clean and disinfect patient equipment used for three residents, which could promote the spread of multi-drug-resistant organisms (MDROs). An LPN used a portable vital sign machine on multiple residents without cleaning it between uses. Despite performing hand hygiene, the LPN did not clean the equipment after each resident, contrary to the facility's policy and CDC guidelines. The Infection Preventionist and Director of Nursing both stated that patient care equipment should be cleaned between each resident and after use. The facility's policies on Enhanced Barrier Precautions and cleaning and disinfection of resident-care items were not followed, leading to potential risks of MDRO transmission. The facility's policy required gown and glove use for high-contact resident care activities, but this was not implemented consistently. Additionally, the policy for cleaning and disinfecting reusable items and durable medical equipment was not adhered to, as evidenced by the LPN's failure to clean the equipment between residents.
Failure to Address Resident Grievance Regarding Incontinence Care
Penalty
Summary
The facility failed to address a grievance from the Responsible Party (RP) regarding the care of a resident, identified as R186. The RP reported that the staff did not change R186's incontinence brief or toilet her regularly, resulting in the resident being frequently saturated with urine. On a specific occasion, the RP found R186 soaked with urine, including her incontinence brief, pants, socks, and shoes. The RP had previously complained to the management about this issue and considered her email to the unit manager, RN1, as a formal grievance. Despite the RP's efforts to communicate the grievance, the facility did not log or address it appropriately. RN1 was unaware of the email until it was brought to her attention during the survey, and the Social Service Director (SSD) confirmed that the grievance had not been logged. The Director of Nursing (DON) was also unsure if the issue rose to the level of a grievance. The Administrator acknowledged that the concern had not been entered into the grievance process and confirmed that the SSD maintained the grievance log.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written transfer notice to a resident and the resident's responsible party when the resident was transferred to the hospital. The resident, identified as R23, was cognitively intact with a BIMS score of 15 out of 15, indicating full cognitive capacity. During an interview, R23 stated she did not remember receiving a written transfer notice when she was sent to the hospital. A review of the resident's electronic medical record revealed a nurse's note indicating the transfer to the hospital due to shock and renal failure, but there was no documentation of a written transfer notice being provided. The facility's administrator confirmed that written discharge/transfer notices were not being provided when residents were sent to the hospital, which was contrary to the facility's policy requiring written notification as soon as practicable.
Failure to Include Stop Date for PRN Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that a resident did not receive an unnecessary medication, specifically an anti-anxiety medication prescribed on a PRN basis without a specified stop date. The facility's policy requires that PRN doses of psychotropic medications are only administered when necessary to treat a specific condition documented in the clinical record, and any continuation beyond 14 days must have a documented rationale. However, the resident, who was admitted with diagnoses including dementia and anxiety and was receiving hospice care, was prescribed Ativan without an end date, contrary to the facility's policy. The resident was administered the PRN Ativan multiple times over a period of several weeks. Interviews with facility staff revealed that the resident exhibited behaviors such as calling out and occasional verbal aggression, which were managed with the PRN Ativan. The staff acknowledged the absence of a stop date in the order, which was typically identified by the pharmacist, but in this case, no recommendation was made. The Director of Nursing confirmed that the PRN order should have included a stop date, indicating a lapse in adherence to the facility's medication management policy.
Failure to Notify Responsible Party of Resident's Condition Changes
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's change in condition, specifically regarding the development of a new pressure injury and the appearance of purple marks. The resident, who was admitted with diagnoses including dementia, anxiety, and contractures, developed an unstageable pressure injury on the left heel. Despite the facility's policy requiring prompt notification of the resident's health care provider and representative in such cases, there was no documentation indicating that the RP was informed about the pressure injury. Interviews with the RP and the Director of Nursing (DON) confirmed that the RP was not notified at the time the pressure injury was identified. Additionally, the facility did not notify the RP when the resident was observed with three purple marks near the right armpit, which were noted as self-induced. The RP stated during an interview that she was unaware of these marks. The facility's failure to communicate these significant changes in the resident's condition to the RP is a clear violation of their policy and represents a deficiency in the standard of care expected in such situations.
Inadequate Assistance with ADLs Leads to Hygiene Deficiencies
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, R186 and R40, leading to deficiencies in maintaining cleanliness and hygiene. R186, who was admitted with Alzheimer's disease and other conditions, required significant assistance with toileting and bathing. Despite being scheduled for weekly showers, R186 did not consistently receive them, with gaps of up to 14 days between showers. Family members reported that R186 was often left saturated with urine, and observations confirmed that her hair was greasy and unkempt. Interviews with staff revealed inconsistencies in toileting schedules, particularly when agency staff were on duty, contributing to the lack of proper care. R40, who was severely impaired and dependent on staff for all ADLs, also did not receive adequate hygiene care. Despite being scheduled for weekly showers, R40 went more than six weeks without a documented shower. Observations noted that R40's hair and beard were long and unkempt, and his skin was dry and flaky. Family members reported finding R40 double diapered and soiled, with dried urine on his bedding. Hospice records indicated that R40 received bed baths and hair washing on some occasions, but not consistently. Interviews with staff highlighted issues with staffing and communication, particularly with agency staff who may not have been aware of the residents' care needs. The lack of a scheduled toileting plan for R186 and the failure to provide regular showers for both residents were significant factors in the deficiencies observed. The facility's failure to adhere to care plans and provide consistent hygiene care resulted in the residents' compromised cleanliness and dignity.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information included the resident census, was posted daily, and maintained for a minimum of 18 months. On 11/14/24, it was observed that the nurse staffing information posted at the entrance of the facility did not include the resident census number. The Director of Nursing (DON) confirmed this omission and revealed that the facility had not been posting the staffing information consistently due to the hiring of a new Staffing Coordinator. The Staffing Coordinator, during an interview, stated that she was unaware of the requirement to post the nurse staffing information until 10/20/24, which was the first day she began posting it. She was unable to provide any staffing information sheets prior to this date, indicating a lapse in maintaining the required records.
Documentation Failures in ADL, Meal Intake, and Treatment Administration
Penalty
Summary
The facility failed to document the provision of activities of daily living (ADLs), the percentage of meals eaten, and the administration of scheduled treatments for several residents. For instance, Resident 4, who was admitted with severe cognitive impairment and was totally dependent on staff for showers and baths, had multiple days in October 2023 where there was no documentation indicating whether a shower or bath was provided. Interviews with staff revealed inconsistencies in documentation practices, with some staff members indicating that there was no option to document refusals in the system, and others stating that gaps in documentation likely meant the care was not charted, not necessarily that it was not provided. Resident 5, who was admitted with quadriplegia and legal blindness, also had significant gaps in documentation for oral care from December 2023 through March 2024. The resident was fully dependent on staff for ADL care, including oral care, which should have been provided every shift. However, multiple days across several months showed no documentation of oral care being provided. Staff interviews confirmed that oral care should be provided daily, but the Director of Nursing acknowledged ongoing documentation issues within the facility. Additionally, Resident 2, who had multiple diagnoses including chronic peripheral venous insufficiency and non-pressure chronic ulcer of the right calf, had missing documentation for wound care on specific dates in September, December, and January. The facility's policy required documentation of wound care, but the treatment records did not reflect that care was provided on these dates. Interviews with staff indicated that wound care should be provided as ordered by the physician, but the Director of Nursing admitted that without proper documentation, it was difficult to prove that the care was administered. Similarly, Resident 1, who was dependent on staff for eating and had a mechanically altered diet, had numerous instances from June to December 2023 where meal intake was not documented, despite the facility's policy requiring routine monitoring of nutritional intake.
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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 Brookfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Care Age | 0.7 mi | — | 1 | 0 |
| Aria Of Brookfield | 1.9 mi | — | 9 | 0 |
| Congregational Home, Inc. | 3.7 mi | — | 0 | 0 |
| Aria Of Waukesha | 4 mi | — | 20 | 1 |
| Lindengrove New Berlin | 6.1 mi | — | 3 | 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.