Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Ridge Health And Rehabilitation Center during CMS and state inspections, most recent first.
A deficiency occurred when a cook used the same pair of single-use gloves, instead of utensils, to handle and plate multiple ready-to-eat items including lettuce, tomatoes, cheese, tortillas, bread, and service ware, resulting in cross-contamination of food during a taco meal service. Three cognitively intact or moderately impaired residents, each with a tomato allergy documented in their records and reflected on their meal tickets, received meals prepared from these potentially cross-contaminated items, including pureed and soft & bite-sized diets. Facility leadership reported that some listed allergies, such as tomatoes, were actually preferences entered in the allergy field due to system limitations, and the cook did not recognize the risk of exposing a resident with a documented tomato allergy to tomato through cross-contact of other foods and equipment.
A resident with intact cognition and multiple chronic conditions had clearly documented lunch preferences on an individualized meal ticket, including two tacos with refried beans in a bowl, diced tomatoes, and gelatin without topping. During meal service, kitchen staff plated the meal with shredded lettuce, which the resident had requested not to receive, and provided gelatin from which whipped topping had been scraped off because no plain gelatin was available. After delivery, the resident and surveyor compared the tray to the ticket and confirmed the discrepancies, with the resident declining to eat the gelatin and having to remove lettuce to access the tomatoes. The Food Services Director later explained the use of weekly meal plans and highlighted tickets to honor preferences, and staff acknowledged the oversight and improper handling of the gelatin.
A resident with severe cognitive impairment and multiple medical conditions was observed wearing a restraint mitt to prevent pulling on a feeding tube, but there was no physician order, assessment, or care plan documentation for its use. Staff could not identify who applied the mitt, and the facility failed to follow required procedures for restraint use, including documentation of less restrictive alternatives and ongoing evaluation.
The facility failed to administer medications within ordered timeframes for several residents with complex medical needs, and did not consistently complete required narcotic counts at shift changes. Nursing staff administered medications hours after scheduled times and did not document controlled substance counts as required, despite facility policy and prior staff education.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from the facility after staff failed to hear and respond promptly to a door alarm. The resident, who was at risk for elopement and equipped with a WanderGuard, was able to leave undetected while staff were providing care in other rooms. The alarm system was not audible in all areas, and staff were unaware of this limitation, resulting in a delayed response and the resident being found two miles away.
Surveyors found that dietary staff did not consistently wear proper hair restraints, maintain kitchen cleanliness, or follow hand hygiene protocols during food preparation and service. Food and beverages were not served at appropriate temperatures, with staff failing to accurately record or monitor food temps. Cleaning logs were incomplete, and resident complaints about food temperature were documented. These deficiencies affected a majority of residents, including those on tube feeding.
A resident with multiple complex medical conditions developed a urinary yeast infection and was prescribed antifungal medication, but the POAHC was not notified of the test results or new treatment. The resident also experienced several episodes of low blood pressure, yet neither the physician nor the POAHC was informed as required by facility policy. Staff interviews and record review confirmed these notification failures.
Staff did not adhere to infection control protocols for two residents, including one on contact precautions for C. diff and another requiring incontinence care. Multiple staff entered a resident's room and provided care without donning required PPE, despite being aware of the need for contact precautions. In a separate incident, a CNA failed to perform hand hygiene between glove changes and did not provide thorough perineal care during incontinence care, contrary to facility policy. These deficiencies were confirmed through direct observation and staff interviews.
The facility failed to obtain necessary guardianship and protective placement orders for three residents and did not honor a resident's advance directive against nursing home placement. The social worker confirmed the lack of a process to ensure proper documentation, and the nursing home administrator acknowledged the oversight in admitting a resident against their stated wishes.
Surveyors found that medication carts were left unlocked and unattended, exposing residents' health information. Expired medications and supplies were also discovered in medication carts and storage rooms. Staff confirmed these deficiencies, acknowledging that night shift nurses should monitor for expired items.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting 33 residents. Observations included unclean kitchen equipment, improper hand hygiene by a cook, and lack of food holding temperature documentation. Additionally, food items were found without discard dates or past their discard dates, indicating non-compliance with FDA Food Code standards.
The facility failed to maintain effective infection control practices, with staff not adhering to hand hygiene and PPE protocols. An APNP did not change gloves during wound care, and staff failed to wear masks in COVID-19 affected areas. A PT did not wear a gown during therapy with a resident on EBP. An LPN did not perform hand hygiene during medication administration. These actions indicate significant deficiencies in infection prevention.
The facility did not ensure that residents were assessed for safe self-administration of medication. An LPN and an RN left medications with residents without physician orders, assessments, or care plans. One resident had intact cognition, another had moderate cognitive impairment, and a third was responsible for their healthcare decisions, yet none had the necessary documentation for self-administration.
A resident with hemiplegia and hemiparesis had their call light out of reach, contrary to their care plan and facility policy. Despite previous grievances and staff education, the issue persisted, highlighting a deficiency in ensuring call light accessibility.
A resident's medical record lacked a Power of Attorney for Healthcare (POAHC) document upon admission, despite having intact cognition and being admitted with serious health conditions. The facility's policy requires advance directives to be documented upon admission, but this was not done. Attempts to obtain the POAHC from the resident's spouse were sporadic and only completed after surveyor intervention, highlighting a lapse in the facility's process.
The facility failed to provide proper written transfer notifications to three residents and their representatives, as required by policy. Verbal authorizations were obtained without the necessary written documentation or signatures. The social worker responsible confirmed the oversight, leading to the deficiency.
The facility failed to provide written bed hold policy notifications to three residents or their representatives during hospital transfers. Despite obtaining verbal authorizations, the facility did not ensure that written notices were signed or documented in the residents' medical records, as required by their Transfer and Discharge policy.
A resident with severe cognitive impairment and a history of pressure injuries did not receive necessary care to prevent new ulcers. Observations revealed the resident's feet were in direct contact with the mattress without required heel boots, and dressings were not changed as ordered. Staff interviews highlighted inconsistencies in following the care plan and physician orders, leading to a deficiency in pressure ulcer care.
A resident with emphysema and COPD, known to smoke, did not receive required quarterly smoking assessments as per the facility's policy. Despite being educated on smoking procedures, the facility failed to conduct assessments in 9/2023, 12/2023, and 3/2024, as confirmed by the DON. This oversight was identified during a survey, highlighting a lapse in maintaining a hazard-free environment.
A facility failed to consistently document and communicate vital signs and weights for a resident undergoing dialysis, as required by their policy. The resident, with end-stage renal disease and CHF, had multiple instances of missing documentation in their medical record and dialysis communication binder. The DON and an RN confirmed these lapses, which were against physician orders and facility policy.
The facility failed to complete and follow up on monthly medication reviews for two residents, resulting in deficiencies. One resident's PRN lorazepam recommendation was delayed by 122 days, and another resident's self-administration assessment for nebulizer treatment was not conducted. Both residents had severe cognitive impairments, and the facility did not act on pharmacist recommendations promptly.
The facility inaccurately submitted staffing data to CMS for fiscal quarters 1 and 2 of 2024, indicating low weekend staffing. This was due to a new payroll system that failed to include salaried employees working weekends. The issue was not detected initially, and the facility had not addressed the reporting inaccuracies before the surveyor's inquiry.
The facility failed to serve pasta salad at a safe temperature, with measurements ranging from 52.5 to 61.7 degrees Fahrenheit, exceeding the safe limit of 41 degrees. Despite being aware of the discrepancy, the kitchen staff did not take immediate corrective action. The Dietary Manager confirmed the facility's adherence to the Wisconsin Food Code and noted that the pasta salad is usually prepared a day in advance to ensure proper cooling, which was not done in this instance.
The facility was found deficient in maintaining sanitary food handling practices, with staff failing to perform proper hand hygiene before donning gloves and touching ready-to-eat food with bare hands. Additionally, unsanitary garbage disposal practices were observed, as staff manually handled garbage can lids after washing hands. These actions were contrary to the Wisconsin Food Code and the facility's hand hygiene policy.
A resident with a history of stroke, chronic respiratory failure, and CHF experienced increased lethargy and low oxygen saturation. The facility failed to document complete assessments or notify the physician promptly, as required by policy. Interviews revealed delays in notifying the provider and incomplete documentation of the resident's condition and care.
The facility failed to monitor weights for two residents with PEG tubes as per physician orders. One resident, with moderate cognitive impairment, missed 48 of 91 daily weights, while another resident, with intact cognition, missed 6 of 11 weekly weights. Staff interviews confirmed the discrepancies in weight monitoring.
A facility failed to prepare and serve pureed diet meals according to the recipe and extended menu for a resident with dysphagia. The cook did not measure chicken broth or serving sizes, and the dietary manager confirmed that the kitchen staff lacked access to updated recipes and serving sizes since a menu change. The resident was on a pureed diet and received tube feeding.
The facility failed to serve milk at a safe and appetizing temperature, with a test tray showing milk at 53.6 degrees Fahrenheit, above the guideline of 41 degrees Fahrenheit or below. The Dietary Manager confirmed the milk was too warm and suggested it was not iced down enough.
A cook was observed preparing coffee cake batter without consistently performing hand hygiene, including touching the storage door's electronic lock and door handle and then returning to food preparation without washing hands. The Dietary Manager confirmed that the cook should have washed hands before continuing to mix the batter.
Improper Glove Use and Cross-Contamination During Meal Service
Penalty
Summary
The deficiency involves failure to ensure food was served under safe and sanitary conditions and in accordance with professional standards, including the FDA Food Code. During observation of a lunch meal service, a cook donned single-use gloves and then used the same gloved hands, rather than utensils, to handle and plate multiple ready-to-eat food items and service ware. With the same pair of gloves, the cook touched shredded lettuce, diced tomatoes, shredded cheese, a bag of soft shell tortillas (inner and outer packaging), a loaf of bread (inner and outer packaging and the bread itself), individually packaged sour cream containers, plates, a plate warmer, scoops for taco meat and refried beans, dessert bowls, trays, and meal tickets. The cook plated meals for residents in the dining room, on the 200 unit, and most of the 500 unit without changing gloves, and changed gloves only once during plating for the 500 unit, by which time the lettuce, tomatoes, and cheese had already been contaminated through cross-contact. The surveyor reviewed medical records and meal tickets for three residents identified on the facility’s allergy list as having tomato allergies. One resident, admitted with traumatic spinal cord dysfunction and cognitively intact per a BIMS score of 14/15, had a diet order for regular texture and thin liquids, and their lunch ticket listed an entrée substitute, starch substitute, vegetable substitute, and sour cream. Another resident, admitted with non-traumatic brain dysfunction and cognitively intact per a BIMS score of 15/15, had a diet order for LCS, pureed texture, and mildly thick (MT2) liquids, with a lunch ticket including taco meat with bread, refried beans, and sour cream; this meal was pureed by the cook prior to service. A third resident, admitted with a neurological condition and moderately impaired cognition per a BIMS score of 11/15, had a regular diet with soft and bite-sized texture, and their lunch ticket included taco meat with bread, refried beans, and sour cream. The surveyor confirmed via the facility’s allergy list and medical records that these three residents were documented as having tomato allergies. The Nursing Home Administrator and DON reported that some items listed as allergies, including tomatoes, were actually resident preferences, and that preferences were entered in the allergy section because there was no place to list preferences on meal tickets. They stated kitchen staff plate food based on meal tickets, and it was not identified by the cook that a resident with a tomato allergy could be exposed to tomato through cross-contamination of lettuce, cheese, tortillas, bread, or equipment that had contacted tomatoes. In a subsequent interview, the Food Service Director verified the cook should have used utensils instead of gloves to plate food and acknowledged the cross-contamination concern, and the cook confirmed that tongs should have been used for shredded lettuce, diced tomatoes, and shredded cheese and acknowledged the potential for cross-contamination that occurred during the meal service.
Failure to Honor Resident Meal Preferences During Lunch Service
Penalty
Summary
The facility failed to honor an identified resident’s stated food preferences during a lunch meal service. The resident, who had intact cognition with a BIMS score of 15 and was their own decision maker, had a diet order for limited concentrated sweets with regular texture and thin liquids, and had completed a weekly meal plan indicating specific preferences. The printed lunch ticket for the resident listed two tacos with refried beans in a bowl, diced tomatoes, and gelatin without topping. During meal plating, the cook prepared two soft shell tacos with taco meat, shredded lettuce, diced tomatoes, shredded cheese, and a bowl of refried beans. The Food Services Director stated the resident requested gelatin without topping, but the only available gelatin cups had whipped topping. The cook scraped the whipped topping off one of the gelatin cups and transferred the gelatin into a new container instead of providing gelatin without topping. When the tray was delivered to the resident, the resident and the surveyor compared the meal ticket to the food served and confirmed that the tray included shredded lettuce, which the resident had requested not to receive, and gelatin that still showed white spots of whipped topping that appeared to have been scraped off. The resident stated they would not eat the gelatin and removed the tomatoes from the pile of lettuce to place them on the tacos. In a subsequent interview, the Food Services Director explained that residents’ choices are recorded on weekly meal plans, which are then used to print and highlight individualized meal tickets to ensure accuracy. When informed of the discrepancy, the cook acknowledged not noticing that the resident did not want lettuce and apologized, and both the cook and the Food Services Director acknowledged that the topping had been scraped off the gelatin and that this should not have occurred.
Failure to Assess, Document, and Care Plan for Use of Physical Restraint Mitt
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including Parkinson's disease, stroke history, COPD, dysphagia, hemiplegia, and schizophrenia, was observed wearing a restraint mitt on the left hand. The facility's policy requires a documented medical symptom, assessment, physician order, and care plan interventions before the use of any physical restraint. However, the resident's medical record lacked any restraint assessment, physician order, or care plan documentation related to the restraint mitt. Staff interviews confirmed the mitt was used to prevent the resident from pulling on a feeding tube, but none could identify who applied it or provide evidence of required documentation or assessment. The resident's care plan did not address the use of the restraint mitt, and there was no documentation of less restrictive alternatives being attempted or ongoing re-evaluation of the restraint's necessity. The Director of Nursing and Nurse Practitioner both confirmed the absence of an order or care plan for the mitt, and the mitt's use was not mentioned in the resident's recent hospital discharge summary. The facility failed to follow its own policy and federal requirements regarding the use of physical restraints, resulting in the imposition of a restraint without proper assessment, documentation, or care planning.
Medication Administration and Narcotic Reconciliation Deficiencies
Penalty
Summary
The facility failed to ensure the accurate administration of medications for four residents, as well as consistent reconciliation of narcotic medications. Surveyors observed that medications for several residents were not administered within the timeframes specified by physician orders and facility policy. For example, one resident with diagnoses including congestive heart failure and chronic pain received furosemide at times significantly later than the ordered administration times, with documentation showing doses given hours after the scheduled times. Another resident with chronic respiratory failure and dependence on a ventilator received multiple medications, all scheduled for early morning administration, several hours late. Similar late administration was observed for two additional residents, both with complex medical histories and scheduled medication times that were not adhered to by nursing staff. Interviews with staff revealed that the nurse responsible for administering morning medications typically began the process after the scheduled time and completed it several hours later, often due to responding to ventilator alarms and other duties. The Director of Nursing confirmed that nurses were allowed up to two hours after the scheduled administration time to give medications, but the observed delays exceeded this window. Residents and staff interviews corroborated that medications were frequently administered outside of the prescribed timeframes, contrary to facility policy and physician orders. Additionally, the facility did not consistently complete required controlled substance counts at shift changes. Review of the Controlled Substance Record Books for multiple wings showed numerous missing signatures for various shifts over a period of several weeks, indicating that narcotic counts were not being verified and documented as required. Staff interviews confirmed that both the outgoing and incoming nurses were responsible for this process, and that it should occur at every shift change. Despite prior education on this requirement, documentation showed ongoing noncompliance with controlled substance reconciliation.
Failure to Provide Adequate Supervision Results in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement and severe cognitive impairment was not provided with adequate supervision, resulting in the resident leaving the facility undetected. The resident had diagnoses including paranoid schizophrenia, epilepsy, panic disorder, anxiety, and depression, and was assessed as being at risk for elopement. The care plan indicated the use of a WanderGuard device and noted the resident's frequent exit-seeking behaviors and moderate fall risk. Despite these interventions, the resident was able to exit the facility through a door equipped with an alarm. On the night of the incident, staff were providing care in residents' rooms and did not hear the door alarm when it was triggered. Multiple staff members confirmed during interviews that the door and WanderGuard alarms were difficult or impossible to hear while inside resident rooms with the doors closed. The alarm was not responded to until several minutes after the resident had already left the facility. The resident was eventually found approximately two miles away, having traversed busy streets and intersections, and was returned to the facility. The facility's policy required staff to be vigilant and respond to alarms in a timely manner, emphasizing that alarms are not a substitute for necessary supervision. However, staff were unaware that the alarm system could not be heard in certain areas, and there was no process in place to ensure alarms were audible throughout the building. Documentation also showed gaps in required 15-minute checks for the resident after the incident. The failure to provide adequate supervision and to respond promptly to the alarm led to the resident's elopement and constituted a finding of immediate jeopardy.
Deficient Food Safety and Sanitation Practices in Dietary Services
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a safe and sanitary manner, as evidenced by multiple observations and staff interviews. Staff did not consistently wear hair restraints that fully covered their hair and facial hair while preparing and serving food, despite facility policy and posted signage requiring full coverage. Specific staff members were observed with exposed hair and beards during meal preparation and service, and staff acknowledged that hair and facial hair should be fully covered at all times in the kitchen. Kitchen equipment and food service areas were not maintained in a clean and sanitary condition. The kitchen floors and shelves in the cook, prep, and serve areas were observed to be dirty and contained debris. Review of cleaning logs revealed that daily cleaning tasks were frequently not completed or documented, with a significant number of assigned tasks left unsigned over several weeks. The Director of Dining confirmed that staff were expected to complete cleaning assignments daily, but this was not occurring as required. Hand hygiene practices were not followed appropriately by staff during food preparation and service. Staff were observed touching food and food-contact surfaces with bare hands, wiping hands on clothing, adjusting glasses, and changing gloves without performing hand hygiene in between. Additionally, food and beverages were not consistently served at appropriate temperatures. Staff failed to obtain and record actual food temperatures during meal service, instead recording fabricated or estimated temperatures on logs. Test trays revealed that most hot and cold foods and beverages were not within the required temperature ranges, and resident grievances and council meeting minutes documented ongoing complaints about improper food temperatures.
Failure to Notify Resident Representative of Change in Condition and Treatment
Penalty
Summary
The facility failed to ensure that a resident's Power of Attorney for Healthcare (POAHC) was notified of significant changes in the resident's condition and treatment. The resident, who had diagnoses including quadriplegia, diabetes mellitus type 2, and a stage 4 sacral pressure ulcer, was found to have yeast in the urine and was prescribed an antifungal medication. Although the POAHC was informed that a urinalysis and urine culture would be performed, there was no documentation that the POAHC was notified of the test results or the initiation of antifungal treatment. The POAHC confirmed not being informed about the results or the new medication order, only learning of further developments when the resident was transferred to the hospital after becoming unresponsive. Additionally, the resident experienced multiple episodes of low blood pressure over two consecutive days. The facility's policy and standing orders required that the physician and the resident's representative be notified of such significant changes, especially when blood pressure readings fell below specified thresholds. However, there was no evidence in the medical record that either the physician or the POAHC was notified of these low blood pressure readings. Interviews with facility staff confirmed that these notifications did not occur, and staff acknowledged that such notifications should have been made. The facility's own policy, revised shortly before the incident, required prompt notification of the resident, physician, and representative in the event of significant changes in condition or treatment. Despite this, documentation and interviews revealed that the required notifications were not consistently made or documented, particularly regarding the new infection, treatment, and episodes of low blood pressure. The deficiency was identified through record review and interviews with the POAHC and facility staff.
Failure to Follow Infection Control Protocols for Residents on Contact Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols for two residents with significant medical needs. One resident, who had a history of malignant neoplasm of the glottis, COPD, chronic respiratory failure, and a tracheostomy, was on contact precautions due to a Clostridioides difficile (C. diff) infection. Despite clear signage indicating contact precautions, multiple staff members, including two CNAs and an RN, entered the resident's room and provided direct care without donning the required personal protective equipment (PPE) such as gowns and gloves. Both the CNAs and the RN acknowledged after the fact that they were aware of the contact precautions and should have worn PPE while in the room. Another resident, with diagnoses including myotonic muscular dystrophy, chronic respiratory failure, encephalopathy, and heart failure, required assistance with toileting and personal hygiene. During an observed episode of incontinence care, a CNA and an LPN donned PPE before entering the room and transferred the resident using a full body lift. However, the CNA did not perform hand hygiene between glove changes, did not cleanse the resident's entire perineal area after a soiled brief was removed, and failed to change gloves before applying barrier cream. The CNA also continued to perform tasks such as changing the resident's gown and cleaning equipment without completing hand hygiene between glove changes, contrary to facility policy. Interviews with staff, including the CNA, LPN, DON, and the Nursing Home Administrator, confirmed that the observed actions did not align with the facility's policies on hand hygiene, perineal care, and transmission-based precautions. The facility's policies require staff to perform hand hygiene before and after glove use, cleanse the entire perineal area during care, and don appropriate PPE for residents on contact precautions. These lapses in infection control practices were directly observed and acknowledged by staff during interviews.
Failure to Obtain Guardianship Orders and Honor Advance Directives
Penalty
Summary
The facility failed to ensure that guardianship and protective placement orders were obtained and advance directive wishes were followed for four residents. Resident 31 had a legal guardian at the time of admission, but their medical record did not contain the necessary guardianship or protective placement orders. Similarly, Resident 43's medical record lacked these orders despite having a legal guardian and a scheduled hearing. Resident 39 also had a legal guardian, but their medical record was missing current protective placement orders. The facility's social worker confirmed that there was no process in place to ensure the documentation of guardianship and protective placement orders in residents' medical records. Resident 30 had completed a Power of Attorney for Healthcare (POAHC) indicating a preference against nursing home placement. Despite this, Resident 30 was admitted to the facility. The social worker verified that the POAHC paperwork was marked 'No' for nursing home placement and acknowledged that the resident should not have been admitted based on their stated wishes. The business office staff and nursing home administrator also confirmed that the facility would typically review such documentation and not admit a resident if they had indicated 'No' to nursing home admission. The deficiencies highlight a lack of proper documentation and adherence to residents' legal and advance directive wishes. The facility did not have a process to ensure that guardianship and protective placement paperwork was obtained and documented, leading to non-compliance with state statutes. Additionally, the facility failed to honor a resident's advance directive, resulting in an admission that contradicted the resident's expressed wishes.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with its policy, as observed by surveyors. Three out of four medication carts were found unlocked and unattended on multiple occasions across different wings of the facility. This included instances where a computer screen displaying residents' health information was left exposed. Staff members, including registered nurses, confirmed that medication carts should be locked when unattended, but admitted to forgetting to do so. Additionally, expired medications and medical supplies were found in two of the medication carts and one of the medication storage rooms. Items such as syringes, eye ointments, and various medications were past their expiration dates. Licensed Practical Nurses verified these findings and acknowledged that night shift nurses were responsible for monitoring the medication carts and storage rooms for expired items. The Director of Nursing confirmed the presence of expired medications and supplies and stated that expiration dates should be checked when loading medication carts.
Sanitation and Hand Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, which had the potential to affect 33 of the 47 residents. During an initial kitchen tour, the surveyor observed dust, dried food debris, and unidentified substances on storage bins of utensils, a broken bin exposing utensils to air, and food debris on preparation surfaces. Additionally, an open bag of sausage links was found on soiled scissors and tinfoil, and dried food debris was noted inside a microwave. The Dietary Manager (DM) acknowledged that cleaning tasks were assigned but not logged or signed off by staff. Hand hygiene practices were also found to be inadequate. A cook was observed preparing lunch without changing gloves or performing hand hygiene despite touching various surfaces and food items. The cook admitted to not knowing the frequency of hand hygiene education, while the DM confirmed that staff were expected to perform hand hygiene after leaving the trayline or touching contaminated surfaces. The DM acknowledged concerns about the cook's hand hygiene during meal service. Furthermore, the facility did not document food holding temperatures unless an audit was being conducted. The DM stated that temperatures were only checked while food was cooking, not during holding. Additionally, several food items in the reach-in cooler and resident refrigerator were found without discard dates or were past their discard dates, including pitchers of lemonade and pre-thickened cranberry juice. These observations indicate a lack of adherence to the FDA Food Code regarding food storage and handling practices.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and personal protective equipment (PPE) usage. During wound care for a resident with a stage 3 coccyx pressure injury, an Advanced Practice Nurse Prescriber (APNP) did not change gloves or perform hand hygiene after handling soiled dressings and before touching clean items. This was confirmed by the Director of Nursing (DON), who acknowledged the breach in protocol. Additionally, staff failed to adhere to mask-wearing protocols in areas with a COVID-19 positive resident. A Certified Nursing Assistant (CNA) and a Registered Nurse (RN) were observed not wearing masks or wearing them improperly while interacting with residents. The DON confirmed that masks should be worn at all times in these areas. Furthermore, during a therapy session with a resident on Enhanced Barrier Precautions (EBP) for carbapenem-resistant Acinetobacter baumannii, a Physical Therapist (PT) did not wear a gown as required, which was verified by both the PT and the DON. The report also highlights several instances of improper hand hygiene during medication administration. A Licensed Practical Nurse (LPN) was observed not performing hand hygiene before and after preparing medications for multiple residents. The DON confirmed that hand hygiene should be completed before medication preparation, after preparation, and after administration. These repeated failures to follow established infection control protocols indicate significant deficiencies in the facility's infection prevention and control practices.
Failure to Assess Residents for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that three residents were assessed as able to safely and accurately self-administer medication. On the specified date, an LPN left medication with a resident for self-administration without a physician's order, self-administration assessment, or care plan indicating the resident could safely do so. This resident had intact cognition and was responsible for their healthcare decisions, yet the necessary documentation and assessments were absent. Similarly, another resident with moderate cognitive impairment and an activated Power of Attorney for Healthcare was left with medication at their bedside without the required physician's order, assessment, or care plan. Additionally, a third resident with intact cognition was provided with a nebulizer solution to self-administer without the necessary documentation or assessment. The Director of Nursing confirmed the lack of appropriate orders, assessments, and care plans for these residents, indicating a systemic issue in the facility's adherence to its self-administration of medication policy.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the resident's care plan. The resident, who was admitted with conditions including hemiplegia and hemiparesis following a cerebral infarction, had a care plan intervention specifically stating that the call light should be within reach due to their risk of falls and other health issues. Despite this, during an observation, the call light was found attached to the bed rail and not accessible to the resident, who confirmed they could not reach it. The facility's policy on call light accessibility was not adhered to, as evidenced by the resident's grievance filed a month prior, which highlighted the same issue of the call light being out of reach after transfers. Although the facility had taken steps to address the grievance by updating the care plan, posting reminders, and educating staff, the deficiency persisted. This was confirmed during an interview with the Director of Nursing, who acknowledged that call lights should be within reach for all residents.
Failure to Document Advance Directives for a Resident
Penalty
Summary
The facility failed to ensure that the medical record contained advance directives for a resident, identified as R13, among the 17 sampled residents. R13 was admitted with diagnoses including congestive heart failure and pulmonary embolism, and had a BIMS score indicating intact cognition. Despite this, R13's medical record did not contain a Power of Attorney for Healthcare (POAHC) document upon admission. The facility's policy requires that advance directives be determined and documented upon admission, but this was not adhered to in R13's case. Interviews and record reviews revealed that the facility did not have R13's POAHC paperwork until after the surveyor's request. The social worker had been in communication with R13's spouse, who had difficulty locating the paperwork. Documentation showed sporadic attempts to obtain the POAHC over a period of years, but the paperwork was only completed and scanned into the medical record after the surveyor's intervention. The facility's staff, including the Nursing Home Administrator and Social Worker, were unable to confirm if the timeframe for obtaining the POAHC was reasonable, indicating a lapse in the facility's process for handling advance directives.
Failure to Provide Proper Transfer Notifications
Penalty
Summary
The facility failed to provide proper notification of transfer or discharge to three residents and their representatives, as required by their policy. Resident 12 was transferred to the hospital due to hypotension and increased lethargy, but the activated Power of Attorney for Healthcare did not receive a written transfer notice. Similarly, Resident 23 was transferred due to paralysis without receiving a written transfer notice, and Resident 31, who was transferred multiple times for various medical reasons, did not have their court-appointed guardian receive written transfer notices. The facility's policy mandates that transfer/discharge notices include information about appeal rights and contact details for the State Long-Term Care Ombudsman, and be provided in a language and manner understandable to the resident and their representative. However, the surveyor's review revealed that verbal transfer authorizations were obtained without the necessary written documentation or signatures from the residents or their representatives. The social worker responsible for ensuring these notices were provided confirmed that the required documentation was not completed, leading to the deficiency.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written notifications of the bed hold policy to three residents or their representatives during hospital transfers. Resident 12 was transferred to the hospital due to hypotension and increased lethargy, but neither the resident nor their Power of Attorney for Healthcare (POAHC) received a written notice of the bed hold policy. Similarly, Resident 23, who was transferred due to paralysis, did not receive a written notice, and the resident confirmed not signing or receiving such a notice. Resident 31 experienced multiple hospital transfers for various medical issues, including abnormal lung sounds and seizure activity, yet neither the resident nor their court-appointed guardian received written notices of the bed hold policy. The facility's Transfer and Discharge policy requires that a notice of transfer and the bed hold policy be provided to residents and their representatives. However, the surveyor's review revealed that the medical records for Residents 12, 23, and 31 lacked documentation of these notices. Although verbal authorizations were obtained, the written notices were not signed by the residents or their representatives, and the Social Worker responsible for ensuring the distribution of these notices confirmed the oversight. This deficiency highlights a failure in the facility's process to ensure compliance with its own policy regarding bed hold notifications.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to ensure that a resident with multiple healed pressure and deep tissue injuries received the necessary care and services to promote healing and prevent new pressure injuries. The resident, who had severe cognitive impairment and a history of pressure injuries, was observed without the required heel boots and pressure-relieving devices, contrary to the care plan and physician orders. The resident's care plan included interventions such as a hip abductor pillow, a pillow between the lower legs, and soft heel boots to prevent pressure injuries. During observations, the surveyor noted that the resident's feet, ankles, and heels were in direct contact with the mattress, and the resident was not wearing heel boots as required. The dressings on the resident's left lateral foot and ankle were dated several days prior, indicating they had not been changed according to the prescribed schedule. The Treatment Administration Record (TAR) showed that the dressings were marked as changed, but the nurse responsible could not recall completing the wound care. Interviews with staff, including a CNA, an APNP, an RN, and the Director of Nursing, revealed inconsistencies in the implementation of the resident's wound care orders. The RN acknowledged that the dressings should have been changed more frequently, and the DON confirmed the expectation for staff to follow physician orders and document care accurately. The failure to adhere to the care plan and physician orders resulted in a deficiency in providing appropriate pressure ulcer care for the resident.
Failure to Conduct Quarterly Smoking Assessments
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards by not conducting quarterly smoking assessments for a resident known to smoke cigarettes. The facility's Smoking Safety policy requires smoking assessments to be completed upon admission, quarterly, and as needed. However, the resident, who was admitted on 6/2/23 and had diagnoses including emphysema and COPD, did not receive the required quarterly assessments in 9/2023, 12/2023, and 3/2024. This oversight was confirmed by the Director of Nursing, who acknowledged that the assessments were not completed as per the facility's policy. The resident, who had a BIMS score indicating intact cognition, was assessed as an unsupervised smoker, with the facility storing their lighter and cigarettes. Despite being educated on the facility's smoking procedure, the lack of timely assessments represents a failure to adhere to the established policy, potentially compromising the safety of the resident and the facility. The deficiency was identified during a survey conducted from 8/12/24 to 8/14/24, where it was confirmed that the necessary education to ensure timely smoking assessments was not initiated.
Inconsistent Documentation of Dialysis Care
Penalty
Summary
The facility failed to ensure consistent documentation and communication of vital signs and weights for a resident receiving dialysis, leading to a deficiency in care. The resident, who was diagnosed with end-stage renal disease and congestive heart failure, required dialysis three times a week. The facility's policy mandated that vital signs and weights be recorded and communicated to the dialysis facility before and after each session. However, the surveyor found multiple instances where this documentation was missing from the resident's medical record and dialysis communication binder. The Director of Nursing and a Registered Nurse confirmed the lapses in documentation, acknowledging that the required pre- and post-dialysis vital signs and weights were not consistently recorded. Specific dates were identified where the resident's pre-dialysis weight, post-dialysis weight, and vital signs were not documented, indicating a failure to adhere to physician orders and facility policy. This lack of documentation and communication could potentially impact the resident's care and treatment outcomes.
Deficiencies in Medication Review and Follow-Up
Penalty
Summary
The facility failed to ensure that monthly medication reviews were completed and followed up on for two residents, leading to deficiencies in medication management. One resident, who was admitted with diagnoses including anoxic brain injury and anxiety, had a pharmacy recommendation from October 2023 to discontinue or create a new order for PRN lorazepam, as PRN psychotropic medication orders cannot exceed 14 days without documented rationale and duration. This recommendation was not addressed until February 2024, 122 days later, during which time the resident was administered lorazepam multiple times. Additionally, there was no documented medication review for this resident in March 2024, despite the resident being present in the facility for most of the month. Another resident, also with severe cognitive impairment, had a pharmacy recommendation from November 2023 to conduct a self-administration assessment for nebulizer treatment. This assessment was not completed, and the resident's ability to self-administer the medication was not documented. The Director of Nursing confirmed the lack of follow-up on these recommendations, indicating a failure in the facility's process to act on pharmacist recommendations in a timely manner.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to ensure the accurate submission of mandatory staffing information to the Centers for Medicare & Medicaid Services (CMS) based on payroll data. This deficiency was identified during a survey when the Payroll Based Journal (PBJ) data for fiscal quarters 1 and 2 of 2024 indicated excessively low weekend staffing. Upon review, it was found that the staff ratios were appropriate according to the Facility Assessment, suggesting that the data submitted to CMS was inaccurate. The Nursing Home Administrator (NHA) and Administrator In Training (AIT) confirmed that the data was not submitted correctly, as the facility had not noticed the issue due to a new payroll system introduced in October 2023. The problem arose because salaried employees, such as the Director of Nursing (DON), who worked on weekends, were not automatically included in the PBJ data submission. This issue was not detected by the facility initially, as no salaried employees worked weekends during the first quarter. The Corporate Business Office Manager (CBOM) was responsible for submitting the staffing data, but there was a lack of communication and follow-up with the surveyor regarding the inaccuracies. The facility had not begun working on a plan to address the system issue for accurate reporting to CMS before the surveyor's inquiry.
Improper Temperature Control of Pasta Salad
Penalty
Summary
The facility failed to ensure that pasta salad was served at a safe and appetizing temperature, as required by the Wisconsin Food Code and the facility's own Food Preparation Guidelines. On the specified date, a surveyor observed kitchen staff preparing and serving a mayonnaise-based cold pasta salad at temperatures significantly above the safe limit of 41 degrees Fahrenheit. The pasta salad was measured at temperatures ranging from 52.5 to 61.7 degrees Fahrenheit, which is above the recommended cold holding temperature. The kitchen staff member responsible for preparing the pasta salad acknowledged the temperature discrepancy but did not take immediate corrective action due to being too busy. The Dietary Manager confirmed that the facility follows the Wisconsin Food Code and that the pasta salad should have been cooled to 41 degrees Fahrenheit or lower before serving. The Dietary Manager also noted that the pasta salad is typically prepared the day before and cooled overnight, but on this occasion, it was made on the same day. Despite previous education on food temperatures, the staff failed to adhere to the facility's food temperature logs and did not check the temperatures before serving. The Nursing Home Administrator expressed an expectation for kitchen staff to follow the established policies for food preparation and serving.
Improper Hand Hygiene and Unsanitary Food Handling Practices
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, as observed during a survey. Multiple instances of improper hand hygiene were noted among the kitchen staff, which included not washing hands before donning gloves, touching ready-to-eat food with bare hands, and handling garbage without subsequent handwashing. Specifically, a cook was seen placing lids on bowls of pasta salad with bare hands, and a dietary aide did the same with residents' drinks. Additionally, the dietary manager was observed picking up an item from the floor, disposing of it in the garbage, and then putting on gloves without washing hands. The kitchen's garbage disposal practices were also found to be unsanitary. The garbage can in use required manual handling to open, which led to staff touching the lid with bare hands after washing. This practice was acknowledged by the dietary manager and other staff as unsanitary. The dietary manager admitted to being nervous and forgetting proper hand hygiene protocols, despite recent training. The facility's failure to adhere to the Wisconsin Food Code and its own hand hygiene policy was evident, as staff sometimes left garbage on a cart instead of disposing of it properly.
Failure to Document and Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident who experienced a change in condition. On the specified date, the resident, who had a history of nontraumatic intracranial hemorrhage, chronic respiratory failure, and congestive heart failure, showed increased lethargy and low oxygen saturation levels. Despite these changes, the staff did not document complete and accurate assessments or notify the resident's physician in a timely manner, as required by the facility's Notification of Changes policy. The resident's medical record indicated that a new medication, trazodone, was administered the evening before the change in condition. On the day of the incident, a registered nurse noted the resident's decline but failed to document all vital signs and assessments conducted. The nurse contacted the nurse practitioner twice, but the documentation was incomplete, and there was a delay in notifying the physician about the resident's condition. Interviews with the Director of Nursing and the Medical Director revealed that the facility did not adhere to the expected protocol of immediate notification of the provider when the resident's condition changed. The Medical Director confirmed that the facility's calls to the medical group's on-call service were delayed, and orders for further evaluation were not promptly executed. The Nursing Home Administrator acknowledged the concerns related to the delay in care and documentation issues.
Failure to Monitor Weights for Residents with PEG Tubes
Penalty
Summary
The facility failed to ensure that two residents with percutaneous endoscopic gastrostomy (PEG) tubes received appropriate treatment and services to prevent adverse consequences of enteral feeding. Resident R10, who had moderate cognitive impairment and was not responsible for their healthcare decisions, had a care plan that required daily weight monitoring due to nutritional problems related to various medical conditions. However, R10's Treatment Administration Record (TAR) showed that 48 out of 91 ordered daily weights were missing. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) confirmed the missing weights and the lack of adherence to the physician's orders. Similarly, Resident R11, who had intact cognition and was responsible for their healthcare decisions, had a care plan that required weekly weight monitoring due to swallowing difficulties and a mechanically altered diet. Despite the order for weekly weights on bath days, R11's TAR indicated that 6 out of 11 weekly weights were not obtained. Interviews with the RN, Certified Nursing Assistant (CNA), and DON verified the missing weights and the failure to follow the prescribed weight monitoring schedule.
Failure to Follow Pureed Diet Recipe and Serving Sizes
Penalty
Summary
The facility failed to ensure that menu items were prepared according to the recipe and served according to the extended menu for a resident on a pureed diet. During a lunch service, the staff did not follow the pureed food recipe and did not use an appropriate serving size for pureed chicken. The cook added chicken broth to baked chicken in a food processor without measuring the broth, and then served the pureed chicken mixture without measuring the serving size. The dietary manager confirmed that the staff should measure the chicken stock to maintain nutritional value and follow portion sizes on the menu. The resident involved had a diagnosis of dysphagia and was on a pureed diet, also receiving nutrition via tube feeding. The dietary manager admitted that the kitchen staff did not have access to pureed diet recipes and serving sizes since the menu was changed, as the book containing these details was not updated. The cook verified not following the recipe and used an unmeasured amount of chicken broth instead of mayonnaise as per the recipe. The extended menu indicated a serving size of 1/3 cup for the pureed chicken sandwich, which was not adhered to.
Milk Served at Unsafe Temperature
Penalty
Summary
The facility did not ensure that milk was served at a safe and appetizing temperature, as observed during a survey. On the specified date, the temperature of milk served on a test tray was recorded at 53.6 degrees Fahrenheit, which is above the facility's guideline of 41 degrees Fahrenheit or below for cold foods. The surveyor observed the kitchen staff preparing room trays for the lunch meal and noted that the milk's temperature was initially 42.8 degrees Fahrenheit when taken from a deep tray containing ice. However, during the delivery process, the meal cart door was left open at times, and the last meal tray was delivered at 12:12 PM. By the time the temperature of the milk on the test tray was checked again at 12:14 PM, it had risen to 53.6 degrees Fahrenheit. The cook acknowledged that the milk was too warm. The Dietary Manager confirmed that milk should be served between 32 and 40 degrees Fahrenheit unless residents request it warmer. Upon reviewing the observation, the Dietary Manager verified that the milk was too warm and suggested that it might not have been iced down enough that day. This deficiency had the potential to affect multiple residents in the facility, excluding those who received nutrition via enteral feeding.
Inadequate Hand Hygiene During Food Preparation
Penalty
Summary
The facility did not ensure staff performed appropriate hand hygiene during food preparation, which had the potential to affect multiple residents. On 5/20/24, a cook was observed preparing coffee cake batter without consistently performing hand hygiene. The cook mixed the batter with a whisk and bare hands, left the food preparation area, touched the storage door's electronic lock and door handle, and then returned to food preparation without washing hands. The cook continued mixing the batter and poured it into a pan before finally washing hands after turning on the oven. The Dietary Manager confirmed that kitchen staff are expected to wash their hands before returning to food preparation after leaving the area. The manager verified that the cook should have washed hands after touching the electronic lock and door handle and before continuing to mix the cake batter. This failure to follow proper hand hygiene protocols was observed and documented by the surveyor.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 78 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Manitowoc
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shady Lane Nursing Care Center | 2.4 mi | — | 0 | 0 |
| St Marys Home For The Aged | 2.6 mi | — | 10 | 0 |
| River's Bend Health Services | 3.1 mi | — | 13 | 0 |
| Complete Care At Manitowoc Llc | 5 mi | — | 6 | 0 |
| Hamilton Health Services | 5.8 mi | — | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.