Inspection Reports for Aria of Brookfield
18740 W BLUEMOUND RD, BROOKFIELD, WI, 53045
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
44.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
863% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
106 residents
Based on a January 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 27, 2025
Visit Reason
The inspection was conducted due to concerns regarding the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, specifically for residents with pressure injuries.
Complaint Details
The investigation was complaint-driven, focusing on the treatment and assessment of pressure injuries for residents R5 and R97. The complaint was substantiated with findings of actual harm due to inadequate skin assessments, delayed treatment initiation, and lack of proper wound care documentation.
Findings
The facility failed to ensure residents with pressure injuries received necessary treatment and services consistent with professional standards. Two residents (R5 and R97) had significant issues: R5 was not comprehensively assessed upon readmission and developed multiple Stage 3 pressure injuries without timely treatment, and R97 had a Stage 3 pressure injury with delayed treatment orders and incomplete wound care documentation.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for residents with pressure injuries.
Report Facts
Residents reviewed with pressure injuries: 5
Residents affected: 2
Stage 3 pressure injuries on R5: 3
Measurement of R5's right buttock pressure injury: 1.6
Measurement of R5's left buttock pressure injury: 1.7
Measurement of R5's coccyx pressure injury: 2.63
Measurement of R97's right 5th toe pressure injury: 1.5
Measurement of R97's right 5th toe pressure injury width: 0.5
Measurement of R97's right 5th toe pressure injury depth: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wound Nurse-F | Wound Nurse | Interviewed regarding wound care responsibilities and treatment orders; involved in treatment of R5 and R97 |
| Director of Nursing-B | Director of Nursing | Interviewed about facility protocol for skin assessments on admission and readmission |
| LPN-AA | Licensed Practical Nurse | Observed completing wound care for R5 |
| Director of Quality Assurance-CC | Director of Quality Assurance | Discussed concerns about R5's readmission skin assessment and wound care |
| CNA-L | Certified Nursing Assistant | Interviewed about assistance and turning needs of R5 |
| CNA-BB | Certified Nursing Assistant | Interviewed about assistance and turning needs of R5 |
Inspection Report
Routine
Deficiencies: 13
Date: Aug 27, 2025
Visit Reason
The inspection was a routine survey of the nursing home facility to assess compliance with regulatory requirements including resident care, medication management, infection control, and other operational standards.
Findings
The facility was found deficient in multiple areas including resident dignity and care preferences, medication management errors, infection control practices, pressure ulcer care, food safety, hospice service coordination, and staffing data accuracy. Several residents experienced lapses in care such as uncovered catheter bags, unmet dietary preferences, psychotropic medication mismanagement, lack of transfer notices, and improper wound care. Infection control protocols were inconsistently followed, and medication errors including expired medications and incorrect administration routes were observed.
Deficiencies (13)
Resident R119's catheter drainage bag was repeatedly uncovered in public view, compromising dignity.
Resident R26's preference for double portions at mealtimes was not consistently implemented and the resident was not informed of diet changes.
Resident R58 had psychotropic medication lorazepam ordered PRN with no stop date and no reassessment after 14 days.
Residents transferred to hospital (R65, R13, R10, R4, R58) did not receive required written transfer notices including appeal rights and advocacy information.
Residents R5 and R97 with pressure injuries did not receive appropriate treatment and services consistent with professional standards to promote healing and prevent new ulcers.
Residents R43 and R20 with enteral feeding tubes did not receive appropriate treatment and services to prevent complications; tube feeding bags were unlabeled or had unknown contents.
Medication management deficiencies including failure to maintain controlled substance logs, medication refrigerators not monitored or maintained, and resident R120 not receiving lidocaine patches as ordered.
Medication error rate was 25.93% with errors including wrong route administration, incorrect dosing, and expired medications given to residents R43, R49, and R120.
Drugs and biologicals were not labeled in accordance with professional principles; expired medications and unlabeled syringes and pills were found in medication carts.
Food storage and preparation practices were not in accordance with professional standards; unlabeled, undated, and expired food items were found in kitchen and resident refrigerators.
Facility failed to establish and maintain an infection prevention and control program; staff did not consistently follow contact and enhanced barrier precautions, hand hygiene, and equipment sanitization protocols for residents R18, R43, R50, R75, and R120.
Resident R113 receiving hospice services did not have hospice orders or a care plan in the medical record upon admission to hospice.
Facility did not ensure mandatory staffing data submitted to CMS for Q2 2025 was accurate; low weekend staffing was not identified or addressed.
Report Facts
Medication error rate: 25.93
Residents affected by medication errors: 3
Residents affected by pressure injury care deficiencies: 2
Residents affected by transfer notice deficiencies: 5
Residents on hospice reviewed: 4
Residents affected by infection control deficiencies: 5
Residents with insulin pens unlabeled or expired: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-X | Licensed Practical Nurse | Observed administering medication incorrectly to R43 and R120, including expired medication and failure to sanitize equipment. |
| DON-B | Director of Nursing | Interviewed regarding multiple deficiencies including medication management, infection control, and staffing data. |
| NHA-A | Nursing Home Administrator | Interviewed regarding facility operations and deficiencies. |
| ADON-C | Assistant Director of Nursing | Interviewed regarding medication administration and infection control practices. |
| CNA-L | Certified Nursing Assistant | Observed not following enhanced barrier precautions and hand hygiene. |
| CNA-M | Certified Nursing Assistant | Observed not following enhanced barrier precautions and hand hygiene. |
| WN-F | Wound Nurse | Interviewed regarding wound care deficiencies. |
| DirQA-CC | Director of Quality Assurance | Interviewed regarding wound care deficiencies. |
| LPN-Q | Licensed Practical Nurse | Interviewed regarding oxygen therapy orders and medication refrigerator monitoring. |
| LPN-Y | Licensed Practical Nurse | Observed administering incorrect vitamin D dose to resident R49. |
| RN-R | Registered Nurse | Observed medication cart deficiencies and unlabeled medications. |
| HSK-K | Housekeeper | Observed not following infection control precautions in resident R50's room. |
| SSD-FF | Social Services Designee | Interviewed regarding hospice service coordination for resident R113. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 10, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of staff-to-resident abuse involving Resident #3.
Complaint Details
The complaint investigation involved Resident #3, who was alleged to have been hit in the head by CNA A and punched in the stomach by Licensed Practical Nurse (LPN) B. The abuse incidents occurred on 05/02/2025 and 05/16/2025. The facility reported the abuse late, after the required two-hour reporting window.
Findings
The facility failed to submit an initial report of an allegation of staff-to-resident abuse to the state survey agency within the required two-hour timeframe for Resident #3. The investigation revealed incidents where Resident #3 was allegedly hit and punched by staff members, with delayed reporting to authorities.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Date of admission: Apr 24, 2025
Assessment Reference Date: May 3, 2025
Incident date: May 2, 2025
Incident date: May 16, 2025
Report submission date: May 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Alleged to have hit Resident #3 in the head during care |
| LPN B | Licensed Practical Nurse | Alleged to have punched Resident #3 in the stomach during care |
| Administrator | Spoke with Resident #3 and POA regarding abuse incidents and reporting |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: May 8, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding abuse of a resident by a family member and concerns about medication management, medication security, and facility safety systems.
Complaint Details
The complaint investigation was substantiated regarding abuse of Resident 17 by a family member (FM2) who hit the resident on the forehead during a family visit. The facility failed to protect the resident from abuse. Police were informed and involved.
Findings
The facility failed to protect a resident from abuse by a family member, had deficiencies in narcotic count documentation and medication security, and the facility-wide security alarm system was not effectively communicated throughout the building, posing risks to resident safety.
Deficiencies (4)
Failed to protect resident from abuse by a family member during a visit, resulting in potential injury.
Failed to ensure both nurses documented accurate narcotic counts at each shift change for three medication carts, with numerous missing signatures.
Failed to ensure medications were secure and medication carts were locked when unattended on the second floor south nursing unit.
Failed to ensure the facility-wide security alarm system was communicated throughout the facility when triggered, limiting alerting staff beyond one nursing station.
Report Facts
Missing narcotic count signatures: 54
Missing narcotic count signatures: 37
Missing narcotic count signatures: 4
Missing narcotic count signatures: 54
Missing narcotic count signatures: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN6 | Licensed Practical Nurse | Confirmed medications left unsecured on desk and medication carts unlocked |
| LPN7 | Licensed Practical Nurse | Observed narcotic count process and confirmed missing signatures |
| Director of Social Services | DOSS | Recounted interview about abuse incident involving Resident 17 |
| Administrator | Informed police about abuse incident and verbalized residents will not experience harm or abuse | |
| Assistant Director of Nursing | ADON | Confirmed narcotic count signature requirements and missing signatures |
| Director of Quality Assurance | QA | Confirmed narcotic count signature requirements and alarm system deficiencies |
| Director of Nursing | DON | Confirmed narcotic count signature requirements and alarm system deficiencies |
| Maintenance Director | Provided information about alarm system monitoring and arming schedule | |
| Registered Nurse | RN1 | Reported inability to hear overhead alarm system when triggered |
| Chief Information Officer | CIO | Participated in interview about alarm system deficiencies |
Inspection Report
Routine
Deficiencies: 12
Date: Jan 29, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including medication consent, resident rights, abuse reporting, care planning, nursing staffing, behavioral health services, pharmaceutical services, dietary services, infection control, and accident prevention.
Findings
The facility was found deficient in multiple areas including failure to obtain written consent for psychotropic medications, lack of prior written notice for room changes, failure to timely report and respond to abuse allegations, incomplete care plans, inadequate assistance with activities of daily living, insufficient nursing staff, inadequate behavioral health services, improper medication management, failure to provide dietary accommodations, and lapses in infection control and accident prevention.
Deficiencies (12)
Failure to obtain written consent explaining risks and benefits of psychotropic medications for resident R26.
Failure to provide prior written notice including reason for room changes for residents R22, R28, R29, and R30.
Failure to timely report suspected abuse and neglect incident involving resident R24.
Failure to respond appropriately to abuse allegations allowing continued care by accused staff for resident R24.
Failure to develop and implement a comprehensive person-centered care plan addressing mood/psychosocial needs for resident R27.
Failure to provide adequate assistance with activities of daily living including incontinence care and showers for residents R25 and R27.
Failure to ensure safety and adequate supervision to prevent accidents for residents R15, R23, and R30.
Insufficient nursing staff to meet resident needs on weekend of 1/25/25-1/26/25, impacting care and call light response times.
Failure to provide necessary behavioral health care and services to resident R22 to attain or maintain highest practicable well-being.
Failure to provide pharmaceutical services meeting resident R26's needs including removal of discontinued medications and timely medication administration.
Failure to provide dietary accommodations and preferences as listed on resident R27's meal tickets.
Failure to maintain an infection prevention and control program including proper hand hygiene and PPE use for residents R25, R24, and R33.
Report Facts
Medication administration late occurrences: 22
Residents affected by staffing shortage: 43
Fall risk assessment score: 16
BIMS score: 15
BIMS score: 8
BIMS score: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DOSS-JJJ | Director of Social Services | Mentioned in relation to failure to obtain medication consents and behavioral health services for R26 and R22. |
| NHA-A | Nursing Home Administrator | Involved in discussions of medication consent, abuse reporting, staffing shortages, infection control lapses. |
| DON-B | Director of Nursing | Involved in discussions of medication consent, abuse reporting, staffing shortages, infection control lapses. |
| LPN-CCC | Licensed Practical Nurse | Documented fall interventions and bed position post fall for resident R15. |
| LPN-I | Licensed Practical Nurse | Documented observation of resident R22 banging head on headboard. |
| UM-FF | Unit Manager/Wound Nurse | Observed performing wound care on resident R24 with lapses in hand hygiene. |
| ICP-II | Infection Control Preventionist | Provided infection control guidance and confirmed PPE requirements. |
| Scheduler-O | Scheduler | Provided staffing schedules and discussed staffing shortages. |
| ADON-C | Assistant Director of Nursing | On-call manager during staffing shortage weekend. |
| DM-MMM | Dietary Manager | Discussed dietary tray preparation and issues with meal ticket adherence. |
| RD-KKK | Registered Dietitian | Discussed dietary tray preparation and issues with meal ticket adherence. |
Inspection Report
Routine
Deficiencies: 8
Date: Dec 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations related to resident care, safety, and facility environment at Aria of Brookfield nursing home.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment in dining areas, ensuring residents received consistent bathing and showering care, providing adequate supervision and safe transfers to prevent accidents, and maintaining proper respiratory care. Additionally, nurse staffing documentation was found to be illegible for 39 days.
Deficiencies (8)
Residents were exposed to unsafe, unclean dining areas with dried food debris, stains, and unclean furniture in multiple dining rooms.
Residents R15 and R11 did not consistently receive showers or bed baths as required by their care plans and physician orders.
Resident R13 walked independently across a busy street to a local restaurant without a safety assessment, contrary to care plan and therapy recommendations.
Resident R12 was transferred using a pivot transfer instead of a Hoyer lift as per care plan, resulting in a laceration requiring 17 stitches.
Resident R14 sustained multiple falls that were not thoroughly investigated and care plan interventions were delayed.
Resident R15 sustained falls and the Wanderguard bracelet was not applied according to manufacturer instructions.
Resident R17's oxygen humidification bottle was empty/dry, contrary to facility policy and physician orders.
The facility did not maintain legible nurse staffing documents for 39 days, potentially affecting all residents.
Report Facts
Residents affected: 95
Number of residents reviewed for bathing: 6
Number of residents reviewed for accidents: 7
Laceration stitches: 17
Oxygen flow rate: 4
Days nurse staffing documents illegible: 39
Residents currently residing: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA-Z | Certified Nursing Assistant | Involved in transfer of R12 when injury occurred |
| LPN-N | Licensed Practical Nurse | Responded to R12's injury and called ambulance |
| Housekeeping-Q | Housekeeping Staff | Interviewed about cleaning schedules and dining area conditions |
| Housekeeping-R | Housekeeping Staff | Interviewed about cleaning schedules and dining area conditions |
| Housekeeping Director-P | Housekeeping Director | Interviewed about cleaning responsibilities and audits |
| Dietary Aide-S | Dietary Aide | Interviewed about dietary staff cleaning responsibilities |
| CNA-T | Certified Nursing Assistant | Interviewed about cleaning responsibilities in dining area |
| NHA-A | Nursing Home Administrator | Informed of multiple findings including dining area and resident care issues |
| DON-B | Director of Nursing | Informed of multiple findings including dining area and resident care issues |
| Regional Director-H | Regional Director | Informed of resident care and safety concerns |
| Director of Quality Assurance-L | Director of Quality Assurance | Informed of resident care and safety concerns |
| LPN-H | Licensed Practical Nurse | Documented and interviewed regarding resident R13 leaving facility |
| CNA-M | Certified Nursing Assistant | Assisted with transfer of R12 when injury occurred |
| ADON-C | Assistant Director of Nursing | Interviewed about resident care plans and fall investigations |
| LPN-HH | Licensed Practical Nurse | Documented and interviewed regarding resident R14 falls |
| LPN-F | Licensed Practical Nurse | Interviewed about oxygen humidifier care for R17 |
| Scheduler-O | Scheduler | Interviewed about nurse staffing form legibility |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Nov 5, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding treatment and care, wound management, medication administration, elopement risk, and hospice coordination at the facility.
Complaint Details
The complaint investigation was triggered by concerns about treatment and care deficiencies, wound management failures, medication errors, elopement risk and supervision, and hospice service coordination. Substantiation status is not explicitly stated.
Findings
The facility failed to provide appropriate treatment and care according to professional standards for multiple residents, including inadequate wound care and monitoring, delayed and incomplete medication administration, insufficient supervision leading to elopement, lack of proper foot care, and poor coordination with hospice services. Several residents experienced harm or were at risk due to these deficiencies.
Deficiencies (7)
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals, including inadequate wound assessment and monitoring for residents R4 and R6.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for residents R1, R2, and R3.
Failure to provide appropriate foot care for residents R1 and R3, including long toenails and inconsistent diabetic foot care.
Failure to ensure adequate supervision and interventions to prevent elopement and ensure safety for resident R5, resulting in elopement and delayed search response.
Failure to provide medically-related social services to resident R5 to attain highest practicable mental and psychosocial well-being, including lack of discharge planning and follow-up on depression.
Failure to ensure resident R5 was free from significant medication errors, including delayed initiation of prescribed antidepressant and lack of documentation of provider notification for medication refusals.
Failure to coordinate hospice services for residents R2 and R3, resulting in inconsistent wound care and lack of hospice awareness of pressure injuries.
Report Facts
Deficiencies cited: 7
WBC lab result: 19.24
Sodium lab result: 127
Potassium lab result: 2.7
Elopement risk score: 2
Elopement risk score: 4
Elopement risk score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-P | Licensed Practical Nurse | Admitted resident R5 and provided information about exit seeking and smoking behaviors. |
| UM-M | Unit Manager | Provided information about resident R5's elopement risk and behaviors. |
| DON-B | Director of Nursing | Interviewed regarding wound care, medication administration, and elopement supervision. |
| NHA-A | Nursing Home Administrator | Interviewed regarding facility policies and responses to deficiencies. |
| NP-R | Psychiatric Nurse Practitioner | Provided psychiatric evaluation and medication orders for resident R5. |
| ADON-B | Acting Director of Nursing | Provided information about wound care coordination and medication administration. |
| CNA-Q | Certified Nursing Assistant | Reported resident R5's exit seeking behaviors and smoking. |
| LPN-T | Licensed Practical Nurse | Provided information about resident R5's behaviors and medication refusals. |
| SSD-W | Social Services Director | Provided information about resident R5's discharge planning and guardianship. |
| LPN-G | Licensed Practical Nurse | Provided information about resident R5's smoking behavior. |
| RN Hospice-I | Registered Nurse Hospice | Provided information about hospice wound care for resident R3. |
| LPN-E | Licensed Practical Nurse | Provided information about hospice wound care for resident R3. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 9, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately notify a resident's physician about significant changes in the resident's condition and weight, and concerns about inadequate supervision to prevent accidents involving residents with aggressive behaviors.
Complaint Details
The complaint investigation focused on Resident 5's weight monitoring and physician notification, and supervision of residents with aggressive behaviors (R4, R3, and R12). The facility failed to notify the physician of significant weight changes for R5 and did not obtain daily weights as ordered. For residents with aggressive behaviors, the facility failed to provide adequate supervision, resulting in verbal and physical altercations that were not properly reported or documented.
Findings
The facility failed to notify the physician of significant weight changes for Resident 5 (R5) and did not obtain daily weights as ordered. Additionally, the facility did not provide adequate supervision and assistance to prevent accidents for residents with aggressive behaviors (R4, R3, and R12), resulting in verbal and physical altercations that were not properly reported or documented.
Deficiencies (2)
Failure to immediately consult the resident's physician regarding significant changes in condition and weight for Resident 5.
Failure to ensure adequate supervision and assistance to prevent accidents for residents with aggressive behaviors (R4, R3, and R12).
Report Facts
Resident weights: 140
Weight change parameters: 3
Weight change parameters: 5
Residents reviewed for physician notification: 3
Residents reviewed for supervision: 4
Residents affected by supervision deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RD C | Registered Dietician | Interviewed regarding facility process for weight monitoring and physician notification |
| RN D | Registered Nurse | Interviewed regarding monitoring of resident weights and physician notification |
| LPN E | Licensed Practical Nurse | Interviewed regarding process for obtaining resident weights and physician notification |
| LPN G | Licensed Practical Nurse | Interviewed regarding weight obtaining process and frequency |
| CNA F | Certified Nursing Assistant | Interviewed regarding process for obtaining resident weights |
| RN H | Unit Manager | Interviewed regarding monitoring and reporting of resident behaviors |
| Dir Act I | Director of Activities | Interviewed regarding resident behaviors and reporting |
| LPN J | Licensed Practical Nurse | Interviewed regarding resident behaviors and staff reporting expectations |
| MT K | Medication Technician | Interviewed regarding resident behaviors |
| LPN L | Licensed Practical Nurse | Interviewed regarding observation and documentation of resident behaviors |
| DON B | Director of Nursing | Interviewed regarding expectations for monitoring and documenting resident behaviors |
| DSS M | Director of Social Services | Interviewed regarding resident behaviors and documentation expectations |
| NHA A | Nursing Home Administrator | Informed surveyor about one-on-one monitoring for resident R4 |
Inspection Report
Routine
Deficiencies: 11
Date: Jul 16, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including medication self-administration, resident privacy, environmental conditions, grievance resolution, discharge planning, activities of daily living, wound care, fall prevention, and infection control.
Findings
The facility was found deficient in multiple areas including failure to assess a resident's ability to self-administer medication, inadequate resident privacy during toileting, poor environmental cleanliness, unresolved resident grievances, ineffective discharge planning for diabetes management, inconsistent shower provision, inadequate wound care and documentation, failure to provide pressure relieving devices, unsafe transfer practices without gait belts, improper bed positioning and call light accessibility, and lapses in infection prevention practices including hand hygiene and use of personal protective equipment.
Deficiencies (11)
Failure to assess resident R99's ability to self-administer medication despite resident's request.
Resident R67 was not provided personal privacy during toileting as bathroom door and privacy curtain were not closed.
Facility environment was not maintained in a safe, clean, comfortable, and homelike condition for 102 residents, with multiple observations of soiled bathrooms, dirty floors, broken fixtures, and pest issues.
Resident grievances for R99 and R501 were not resolved promptly or documented properly, lacking signatures, investigation details, and resolution confirmation.
Discharge planning for resident R501 did not include effective diabetes teaching or preparation for blood glucose monitoring and medication administration.
Resident R99 did not consistently receive showers twice a week as required by facility policy.
Resident R53 had an undated bandage on right second toe with bloody drainage without prior assessment or physician notification.
Residents R26, R77, R53, and R99 did not receive wound care treatments consistent with physician orders and professional standards, including incorrect transcription of orders, conflicting treatments, delayed implementation, and incomplete documentation.
Resident R67, at high risk for falls, was transferred without use of a gait belt on multiple occasions.
Resident R53's bed was observed not at the lowest position and call light was not within reach as required by care plan.
Facility staff did not maintain infection prevention and control practices including failure to perform hand hygiene after toileting, failure to wear gowns during care and treatment of residents on enhanced barrier precautions.
Report Facts
Residents affected: 1
Residents affected: 5
Residents affected: 102
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-F | Licensed Practical Nurse | Named in wound care treatment and infection control deficiencies including failure to wear gown and delayed treatment implementation |
| NHA-A | Nursing Home Administrator | Named in grievance resolution deficiencies and informed of multiple findings |
| DON-B | Director of Nursing | Named in multiple findings including wound care, fall prevention, infection control, and grievance resolution |
| Director of QA-I | Director of Quality Assurance | Named in wound care, infection control, and grievance resolution findings |
| LPN-G | Licensed Practical Nurse | Named in wound care and fall prevention findings |
| CNA-M | Certified Nursing Assistant | Named in transfer and infection control deficiencies including failure to use gait belt and hand hygiene |
| CNA-P | Certified Nursing Assistant | Named in infection control deficiencies including failure to perform hand hygiene |
| MDS/RN-T | Minimum Data Set/Registered Nurse | Named in infection control deficiencies including failure to wear gown |
| WP-H | Wound Physician | Named in wound care treatment order and assessment deficiencies |
| SSD-C | Social Service Director | Named in discharge planning deficiencies |
Inspection Report
Routine
Deficiencies: 12
Date: May 22, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found to have multiple deficiencies including unclean and unsafe environments, inadequate grievance documentation and resolution, incomplete transfer and discharge documentation, insufficient bathing assistance, inadequate care and assessment of pressure injuries, improper tube feeding practices, insufficient staffing levels, and poor food handling and sanitation practices.
Deficiencies (12)
Facility did not ensure a clean, sanitary and homelike environment; dirty floors, unmade beds without fitted sheets, debris scattered, and pill found on floor.
Facility did not ensure grievances were documented or promptly resolved for a resident with missing personal items.
Facility did not ensure residents' medical records included documentation of reasons for transfer or discharge and appropriate communication to receiving providers.
Facility did not ensure discharge summaries were completed to communicate necessary information to residents and providers at discharge.
Resident was not provided bathing assistance as per care plan; bathing documentation was incomplete.
Facility did not ensure appropriate care and assessment for residents with wounds and pressure injuries; wounds were not properly staged or treated and care plans were not updated timely.
Facility did not ensure adequate supervision and fall prevention measures; falls were not comprehensively assessed and root cause analyses were incomplete.
Resident with gastrostomy tube received unprescribed tube feeding formula; feeding bags were not labeled with date, time, rate, or total run time.
Facility did not ensure sufficient nursing staff to meet resident needs; staffing shortages were documented in payroll data and resident concerns were reported.
Facility did not ensure food was stored, prepared, and served in a sanitary manner; staff failed to change gloves or wash hands appropriately, food temperatures were not properly taken, food was not labeled with use-by dates, staff did not wear beard restraints, and medication was stored with food in refrigerators.
Facility did not ensure complete and accurate documentation in medical records for a resident who died; assessments at time of death and notification to hospice were not documented.
Facility did not ensure timely monitoring of side effects for residents on antipsychotic medications; AIMS assessments were missing or outdated.
Report Facts
Deficiencies cited: 13
Residents affected: 104
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-G | Licensed Practical Nurse | Spoke about fitted sheets availability and resident care concerns |
| LS-O | Laundry Staff | Reported lack of queen size fitted sheets and management awareness |
| CIO-H | Chief Innovation Officer | Discussed fitted sheets, grievance process, and staffing issues |
| SW-E | Social Worker / Grievance Officer | Discussed grievance process and missing resident items |
| NHA-A | Nursing Home Administrator | Discussed grievances, transfers, staffing, and resident care concerns |
| DON-B | Director of Nursing | Discussed wound care, fall protocols, and resident care |
| LPN-I | Licensed Practical Nurse | Completed wound evaluation and treatment for resident R81 |
| NP-L | Nurse Practitioner | Provided wound care assessments and treatment |
| RN-F | Registered Nurse | Assessed resident R259 during penile erosion incident |
| CNA-V | Certified Nursing Assistant | Involved in resident R11 fall and transfer from floor |
| CNA-W | Certified Nursing Assistant | Assisted with resident R11 fall and transfer from floor |
| Agency RN-Y | Agency Registered Nurse | Assisted with resident R11 fall and transfer from floor |
| LPN-X | Licensed Practical Nurse | Described protocol for transferring residents from floor |
| DQA-D | Director of Quality Assurance | Discussed staffing and wound care assessments |
| DR-N | Director of Rehab | Discussed resident R11 transfer status and therapy |
| Dietary Aide-DD | Dietary Aide | Observed handling food with contaminated gloves and improper food temperature monitoring |
| Dietary Aide-EE | Dietary Aide | Observed handling food with contaminated gloves and improper food temperature monitoring |
| Cook-CC | Cook | Observed working without beard cover |
| Dietary Aide-FF | Dietary Aide | Observed working without beard cover |
Inspection Report
Routine
Deficiencies: 24
Date: May 22, 2024
Visit Reason
The inspection was a routine survey of the nursing home facility to assess compliance with regulatory requirements including resident care, safety, infection control, staffing, and other operational standards.
Findings
The facility was found deficient in multiple areas including resident dignity and care, notification and documentation of grievances, infection control practices, medication management, staffing levels, fall prevention, pressure ulcer care, hospice coordination, and food safety. Several residents were noted to have unmet care needs, incomplete documentation, and inadequate staff supervision.
Deficiencies (24)
Resident R82's catheter drainage bag was observed uncovered multiple times, violating dignity and infection prevention standards.
Resident R16 did not have an activated Power of Attorney and facility allowed an unactivated POA to sign consents without proper documentation.
Facility environment was unclean and unsanitary on multiple units with dirty floors, debris, and improper linen management.
Resident R58's grievances regarding missing personal items were not documented or resolved appropriately.
Three facility staff lacked required background information disclosure forms upon hire.
Residents R64 and R96 were transferred to hospitals without adequate documentation of transfer reasons or communication.
Resident R82 did not receive bathing assistance as required by care plan; only one shower documented in 30 days.
Residents R26 and R81 did not receive appropriate treatment and care; R26 missed urologist appointments without documented education or follow-up, and R81 had blisters not comprehensively assessed or treated.
Residents R18, R40, R67, and R11 had falls that were not comprehensively assessed, with inadequate interventions and root cause analyses to prevent future falls.
Resident R17 received unprescribed tube feeding formula and tube feeding bags were not labeled with date, time, rate, or total run time.
Facility staffing was insufficient at times, with documented low weekend staffing and residents reporting ignored call lights and inadequate staff availability.
Pharmacist recommendations for residents R64 and R11 were not acted upon or documented appropriately.
Residents R27, R64, and R34 signed binding arbitration agreements without proper explanation or assessment of understanding.
Resident R16's hospice plan of care and communication from hospice agency were not available to facility staff, and hospice documentation was incomplete.
Residents R17, R81, and R75 with indwelling devices were not placed on enhanced barrier precautions as required.
Resident R40's pressure injury was incorrectly staged and treated, resulting in worsening of the wound to stage 4.
Resident R259 developed penile erosion from Foley catheter that was not recognized or assessed timely by the facility.
Resident R81's blister wounds were not assessed or treated timely and appropriately, and enhanced barrier precautions were not implemented promptly.
Resident R75 with nephrostomy bag did not have enhanced barrier precautions implemented as required.
Resident R258's death was not documented in nursing notes, hospice was not notified timely, and post-death documentation was inaccurate.
Residents R40 and R67 had falls with incomplete assessments and interventions; R18 fell out of bed resulting in aspiration pneumonia; R11 was lowered to floor and sustained a thoracic fracture.
Medications and biologicals were not properly labeled or stored in locked compartments in multiple medication carts and storage rooms, including undated opened bottles and insulin pens without identifiers.
Dietary staff failed to follow proper hand hygiene and glove use during food preparation and service; food temperatures were not properly taken or recorded; food was not labeled with use-by dates; staff did not wear beard restraints; medication was stored with food in unit refrigerators with inconsistent temperature monitoring.
Facility infection prevention and control program was not fully implemented; infection surveillance, tracking, trending, and reporting were incomplete; water management plan was inadequate; enhanced barrier precautions were inconsistently applied; and antibiotic stewardship program was not effectively implemented.
Report Facts
Residents receiving antibiotics: 7
Staff on duty: 7
Staff on duty: 5
Staff on duty: 6
Pressure injury measurement: 2
Pressure injury measurement: 7.2
Pressure injury measurement: 1.8
Pressure injury measurement: 6.6
Pressure injury measurement: 4.9
Pressure injury measurement: 1.8
Pressure injury measurement: 0.9
Pressure injury measurement: 0.7
Pressure injury measurement: 1
Pressure injury measurement: 0.5
Pressure injury measurement: 0.1
Pressure injury measurement: 4.5
Pressure injury measurement: 1.5
Pressure injury measurement: 0.1
Pressure injury measurement: 4
Pressure injury measurement: 1
Pressure injury measurement: 0.4
Pressure injury measurement: 2
Pressure injury measurement: 4
Pressure injury measurement: 0.4
Pressure injury measurement: 1.4
Pressure injury measurement: 1.8
Pressure injury measurement: 0.6
Pressure injury measurement: 1.1
Pressure injury measurement: 3.8
Pressure injury measurement: 0.1
Pressure injury measurement: 4.6
Pressure injury measurement: 3.9
Pressure injury measurement: 1.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON)-B | Director of Nursing | Interviewed regarding catheter dignity, bathing, falls, wound care, infection control, and penile erosion |
| Nursing Home Administrator (NHA)-A | Nursing Home Administrator | Interviewed regarding catheter dignity, bathing, falls, wound care, infection control, hospice, staffing, and arbitration agreements |
| Social Worker (SW)-E | Social Worker | Interviewed regarding grievances, POA activation, hospice coordination, and psychotropic medication monitoring |
| Certified Nursing Assistant (CNA)-V | Certified Nursing Assistant | Involved in resident transfer and fall incident |
| Agency RN-Y | Registered Nurse | Involved in resident transfer and fall incident |
| Licensed Practical Nurse (LPN)-G | Licensed Practical Nurse | Interviewed regarding falls and enhanced barrier precautions |
| Director of Quality Assurance (Dir QA)-D | Director of Quality Assurance | Interviewed regarding grievances, infection control, antibiotic stewardship, and wound care |
| Chief Innovation Officer (CIO)-H | Chief Innovation Officer | Interviewed regarding staffing, grievances, and arbitration agreements |
| Licensed Practical Nurse (LPN)-I | Licensed Practical Nurse | Provided wound care and documented skin impairment |
| Director of Rehab (DR)-N | Director of Rehabilitation | Interviewed regarding resident therapy and transfer status |
| Licensed Practical Nurse (LPN)-X | Licensed Practical Nurse | Interviewed regarding protocol for transferring residents from the floor |
| Admissions-U | Admissions Personnel | Interviewed regarding explanation of arbitration agreements |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 5, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to comprehensively assess and document a resident fall that occurred on 2/7/24.
Complaint Details
The visit was complaint-related due to concerns about inadequate assessment and documentation of a resident fall. The complaint was substantiated as the facility failed to conduct or document the required post-fall assessment and care plan revisions.
Findings
The facility did not ensure that resident R1's fall on 2/7/24 was comprehensively assessed or documented, and the care plan was not revised accordingly. Interviews and record reviews confirmed missing vital signs, neuro-checks, and assessment documentation post-fall.
Deficiencies (1)
Failure to comprehensively assess and document a resident fall, including vital signs and neuro-checks, and failure to revise the care plan accordingly.
Report Facts
Residents reviewed with falls: 3
Residents affected: 1
Date of fall: Feb 7, 2024
Date of survey: Mar 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA-E | Certified Nursing Assistant | Provided staff statement regarding resident R1's fall and was interviewed about the incident |
| UM-D | Unit Manager | Reviewed Resident Fall Data Form and provided information about fall packet usage and interdisciplinary meetings |
| RDCO-C | Regional Director of Clinical Operations | Oversaw Director of Nurses role, commented on agency staff orientation and documentation concerns |
| Administrator-A | Administrator | Addressed concerns with fall assessment and documentation with the administration team |
| Director of Nurses-B | Director of Nurses | Participated in discussion regarding fall assessment concerns |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 9, 2024
Visit Reason
The inspection was conducted to assess compliance with medication administration policies, specifically to determine if residents were properly assessed for self-administration of medications.
Findings
The facility failed to ensure that 2 of 3 sampled residents with empty medication cups at bedside were assessed for self-administration of medications, posing a potential risk of medications not being taken as required. Interviews and record reviews confirmed no assessments had been conducted for self-administration.
Deficiencies (1)
Facility failed to ensure 2 of 3 residents observed with empty medication cups at bedside were assessed for self-administration of medication.
Report Facts
Residents sampled: 8
Residents affected: 2
BIMS score: 10
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Technician | Interviewed about medication administration practices | |
| Director of Nursing | Stated no residents had been assessed for self-administration of medication |
Inspection Report
Annual Inspection
Census: 106
Deficiencies: 3
Date: Jan 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident environment, wound care, restorative services, and overall facility conditions.
Findings
The facility was found to have multiple deficiencies including unclean and poorly maintained resident rooms and common areas, failure to provide and document wound care for residents, and lack of restorative nursing services for residents with limited mobility.
Deficiencies (3)
Facility failed to ensure resident rooms, dining rooms, and hallways were clean and/or in good repair, creating a homelike environment.
Facility failed to ensure wound care was documented as being provided for 2 of 2 residents reviewed for non-pressure wounds.
Facility failed to ensure 1 of 3 residents reviewed for limited mobility received restorative services as needed to maintain or improve mobility.
Report Facts
Residents affected: 106
Residents affected: Many
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Confirmed second-floor dining room floor and carpets were in need of cleaning |
| NHA A | Nursing Home Administrator | Acknowledged facility maintenance issues and cleanliness concerns |
| UM D | Unit Manager | Commented on dining room flooring condition and wound care treatments |
| DON B | Director of Nursing | Confirmed wound care treatments were not documented as completed and provided therapy notes |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Oct 16, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify residents' families of significant changes in condition, inadequate care including weight monitoring and pressure injury management, privacy violations, environmental safety concerns, inadequate assistance with activities of daily living, pressure injury care deficiencies, nutritional deficits, pain management issues, dialysis medication communication failures, insufficient RN coverage, pharmaceutical service deficiencies, and infection control lapses.
Complaint Details
The complaint investigation revealed multiple areas of noncompliance including failure to notify families of significant condition changes, inadequate care and monitoring, privacy violations, environmental hazards, insufficient assistance with activities of daily living, pressure injury care deficiencies, nutritional and hydration inadequacies, pain management failures, dialysis medication communication issues, insufficient RN coverage, pharmaceutical service errors, and infection control lapses.
Findings
The facility failed to notify residents' families of significant condition changes for 2 residents, did not maintain privacy during care for 2 residents, had environmental hazards and cleanliness issues affecting multiple residents, failed to provide adequate assistance with activities of daily living for 1 resident, did not provide appropriate pressure injury care for 1 resident resulting in worsening wounds, failed to maintain adequate nutrition and hydration for 3 residents leading to weight loss and impaired healing, did not provide consistent pain management for 1 resident, lacked communication regarding dialysis medication orders for 1 resident, did not ensure RN coverage for 14 days over 4 months, had pharmaceutical service deficiencies including insulin administration errors and storage issues, and failed to maintain infection prevention and control practices including hand hygiene and laundry handling.
Deficiencies (11)
Failure to notify residents' families of significant changes in condition for 2 residents (R13 and R17).
Failure to maintain personal privacy during care for 2 residents (R3 and R18).
Environmental hazards and cleanliness issues affecting multiple residents including broken corner guards, stains, clutter, and soiled floors.
Failure to provide adequate assistance with activities of daily living for 1 resident (R2), including lack of intervention for care refusals.
Inadequate pressure injury care for 1 resident (R17) resulting in worsening stage 4 and stage 3 pressure injuries and severe weight loss.
Failure to maintain adequate nutrition and hydration for 3 residents (R17, R2, R12) resulting in weight loss and impaired healing.
Inadequate pain management for 1 resident (R7) including failure to assess pain and delayed administration of pain medication.
Failure to ensure consistent communication and administration of dialysis medications for 1 resident (R1), resulting in missed doses of vancomycin.
Failure to ensure RN coverage for a minimum of eight consecutive hours a day on 14 days over a four-month period.
Pharmaceutical service deficiencies including insulin administration errors (failure to prime insulin pens), lack of opened date on insulin pens, and improper storage of insulin pens for multiple residents.
Failure to maintain infection prevention and control practices including inadequate hand hygiene during medication administration and dressing changes, improper handling of soiled laundry, and failure to sanitize multi-resident glucometer.
Report Facts
RN coverage missing days: 14
Weight loss percentage: 13.65
Meal intake documentation missing: 29
Meal intake documentation missing: 36
Fluid intake documented days: 11
Insulin doses administered: 3
Vancomycin doses dispensed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN II | Licensed Practical Nurse | Observed administering insulin without priming pen and poor hand hygiene during medication pass |
| DON B | Director of Nursing | Interviewed regarding RN coverage, wound care, dialysis communication, insulin administration, and infection control |
| CNA I | Certified Nursing Assistant | Primary caregiver for R2, described challenges with care refusals and documentation |
| RD E | Registered Dietician | Interviewed regarding nutritional assessments and recommendations for R2 and R17 |
| MD V | Wound Care Doctor | Provided wound care recommendations for R17 |
| DM EE | Dialysis Manager | Interviewed regarding dialysis medication administration for R1 |
| LPN K | Licensed Practical Nurse | Interviewed regarding documentation of resident refusals |
| MT BB | Medication Technician | Observed during medication pass and pain medication administration for R7 |
| CNA D | Certified Nursing Assistant | Observed providing care without proper hand hygiene |
| LPN C | Licensed Practical Nurse | Observed performing dressing change without proper hand hygiene |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: May 11, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, safety, grievance resolution, activities of daily living, nutrition, and enteral feeding.
Findings
The facility was found to have multiple deficiencies including failure to maintain a clean environment, inadequate grievance investigation and resolution, failure to provide timely bed hold notices, insufficient assistance with activities of daily living such as bathing and grooming, failure to maintain acceptable nutritional status and weight monitoring, and improper administration of enteral feeding without checking gastrostomy tube placement.
Deficiencies (6)
Malodorous garbage/soiled linen bins left in hallways and bed linens piled on the floor, creating an unsafe and unclean environment.
Failure to promptly investigate and resolve grievances for residents, including lack of documentation and follow-up on complaints about staff interactions and equipment issues.
Failure to provide bed hold notice upon resident transfer to hospital for one resident.
Failure to provide necessary assistance with activities of daily living including bathing, grooming, and nail care for two residents.
Failure to maintain acceptable nutritional status and follow weight monitoring orders, including lack of re-weighs after significant weight loss and use of inaccurate weights for nutritional assessment.
Failure to ensure proper procedure for enteral feeding administration by not checking gastrostomy tube placement prior to feeding.
Report Facts
Residents affected: 17
Residents affected: 20
Residents affected: 4
Residents affected: 4
Residents affected: 4
Weight loss percentage: 7.49
Weight loss in pounds: 101.6
Weight: 237
Weight: 250.8
Weight: 220
Weight: 301
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON-B | Director of Nursing | Interviewed regarding environmental concerns, grievance process, resident grooming, weight monitoring, and enteral feeding administration |
| NHA-A | Nursing Home Administrator | Interviewed regarding grievance process, bed hold notices, weight monitoring, and facility management |
| LPN-E | Licensed Practical Nurse | Interviewed regarding resident R41 incident with agency staff and Hoyer lift |
| SW-I | Social Worker | Interviewed regarding resident R41 incident and follow-up |
| Activity Director-L | Activity Director | Interviewed regarding Resident Council meetings and follow-up on resident concerns |
| Maintenance Director-K | Maintenance Director | Interviewed regarding Hoyer lifts and battery charging issues |
| RD-H | Registered Dietitian | Interviewed regarding resident weight monitoring and nutritional assessments |
| RN Supervisor-G | Registered Nurse Supervisor | Interviewed regarding shower documentation, nail care, and weight monitoring |
| LPN-O | Licensed Practical Nurse | Observed administering enteral feeding without checking gastrostomy tube placement |
Inspection Report
Routine
Census: 37
Deficiencies: 2
Date: May 10, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding maintaining a safe, clean, comfortable, and homelike environment for residents.
Findings
The facility was found to have malodorous garbage/soiled linen bins left in the hallway and a pile of bed linens on the floor in the hallway, which violated standards for cleanliness and safety. These issues potentially affected 37 residents across two units. Facility leadership acknowledged the concerns and had meetings regarding the issue.
Deficiencies (2)
Two garbage/soiled linen bins in the hallway of 2 east were visibly full and malodorous.
A pile of bed linens was lying on the floor in the hallway of 1 south with no barrier between linens and floor.
Report Facts
Residents affected: 17
Residents affected: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON-B | Director of Nursing | Interviewed regarding the environmental concerns and facility practices about garbage and linens in hallways |
| NHA-A | Nursing Home Administrator | Informed about environmental concerns relayed by DON-B |
| CIO-C | Corporate Innovations Officer | Informed about environmental concerns relayed by DON-B |
Inspection Report
Routine
Deficiencies: 14
Date: Apr 3, 2023
Visit Reason
The inspection was a routine survey of the nursing home facility to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The survey identified multiple deficiencies including failure to ensure effective communication with a deaf resident, inadequate accommodations for resident needs, failure to notify a resident's representative of significant changes, environmental cleanliness issues, incomplete background checks for staff, failure to timely report suspected abuse, inadequate discharge planning, insufficient assistance with activities of daily living, improper pressure ulcer care leading to decline and amputation, inadequate catheter care, poor food quality and temperature, lack of psychosocial support, and incomplete staff training on abuse prevention and dementia care.
Deficiencies (14)
Failure to ensure effective communication with a deaf resident and lack of staff training on communication methods.
Failure to reasonably accommodate resident needs including call light accessibility and provision of ice.
Failure to notify resident's representative of significant change in condition and treatment.
Environmental cleanliness issues including dirty floors, peeling paint, dust accumulation, and debris in resident rooms and common areas.
Failure to complete required background screenings for staff upon hire and every four years.
Failure to timely report suspected abuse to local law enforcement.
Failure to thoroughly investigate allegations of abuse including incomplete staff interviews and unclear identification of accused staff.
Inadequate discharge planning for residents including lack of updated care plans and failure to assist with discharge goals.
Failure to provide necessary assistance with activities of daily living including bathing per care plan.
Failure to provide appropriate pressure ulcer care and prevent decline, resulting in immediate jeopardy and amputation.
Failure to provide appropriate catheter care including improper infection control and failure to empty catheter bags regularly.
Failure to ensure food is palatable, attractive, and served at a safe and appetizing temperature.
Failure to provide medically related social services to residents to attain or maintain highest practicable well-being.
Failure to ensure nurse aides complete required annual training on abuse prevention and dementia care.
Report Facts
Background screenings missing: 2
CNA training missing: 4
Foley catheter care missed: 47
Pressure injury stages: 3
Shower documentation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA N | Certified Nursing Assistant | Named in background screening and training deficiencies. |
| CNA L | Certified Nursing Assistant | Named in background screening deficiencies. |
| CNA H | Certified Nursing Assistant | Named in training deficiencies. |
| CNA I | Certified Nursing Assistant | Named in training deficiencies. |
| CNA O | Certified Nursing Assistant | Named in training deficiencies. |
| Director of Social Services DSS-C | Director of Social Services | Named in communication and psychosocial care deficiencies. |
| Wound NP-CC | Nurse Practitioner | Named in pressure ulcer care deficiencies. |
| Human Resources HR-K | Human Resources | Named in background screening deficiencies. |
| Dietary Manager DM-M | Dietary Manager | Named in food quality deficiencies. |
| Certified Nursing Assistant CNA-U | Certified Nursing Assistant | Named in catheter care deficiencies. |
| Licensed Practical Nurse LPN-U | Licensed Practical Nurse | Named in pressure ulcer care deficiencies. |
| Licensed Practical Nurse LPN-GG | Licensed Practical Nurse | Named in pressure ulcer care deficiencies. |
| Licensed Practical Nurse LPN-Q | Licensed Practical Nurse | Named in pressure ulcer care deficiencies. |
| Advanced Practice Nurse Prescriber APNP-KK | Advanced Practice Nurse Prescriber | Named in pressure ulcer care deficiencies. |
| Certified Nursing Assistant CNA-FF | Certified Nursing Assistant | Named in pressure ulcer care deficiencies. |
| Certified Nursing Assistant CNA-JJ | Certified Nursing Assistant | Named in pressure ulcer care deficiencies. |
| Certified Nursing Assistant CNA-Y | Certified Nursing Assistant | Named in food service deficiencies. |
| Dietary Aide DA-Z | Dietary Aide | Named in food service deficiencies. |
| Chief Innovations Officer CIO-J | Chief Innovations Officer | Named in abuse reporting and investigation deficiencies. |
| Nursing Home Administrator NHA-A | Nursing Home Administrator | Named in multiple deficiencies including abuse reporting, discharge planning, and staff training. |
| Director of Nursing DON-B | Director of Nursing | Named in multiple deficiencies including abuse reporting, discharge planning, catheter care, and staff training. |
| Social Worker SW-P | Social Worker | Named in discharge planning deficiencies. |
| Social Services Director SSD-C | Social Services Director | Named in psychosocial care deficiencies. |
| Licensed Practical Nurse LPN-I | Licensed Practical Nurse | Named in abuse investigation deficiencies. |
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