Inspection Reports for Burlington Health and Rehabilitation Center
WI, 53105
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
35.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
667% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
74 residents
Based on a May 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 22, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to regularly offer alternate meals of equal nutritional value to residents who declined the originally served meal.
Findings
The facility failed to ensure that three residents out of 18 reviewed were regularly offered alternate meals of equal nutritional value when they declined the meal served. Observations and interviews confirmed that only one alternate main entree was offered daily, with no alternate vegetables or starches, negatively impacting residents' dining experience and potentially causing weight loss.
Complaint Details
The complaint investigation found that three residents (R2, R18, and R23) were not regularly offered alternate meals of equal nutritional value. The complaint was substantiated based on record review, observations, and interviews.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents were regularly offered alternate meals of equal nutritional value when declining the originally served meal. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed in sample: 26
Residents in sample reviewed for meal choices: 18
Residents affected: 3
BIMS score: 12
Assessment Reference Date: 112725
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Services Manager | Confirmed only one alternate main entree served daily and no alternate vegetables or starches | |
| Registered Dietician | Confirmed expectation that alternates of equal nutritive value should be available and menus posted |
Inspection Report
Routine
Deficiencies: 21
Aug 13, 2025
Visit Reason
The inspection was a routine regulatory survey of Burlington Health and Rehabilitation Center to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, self-determination, communication privacy, advance directive documentation, environmental cleanliness, abuse prevention and reporting, accurate resident assessments, activities of daily living assistance, respiratory care, pain management, infection control, pest control, and staffing data reporting.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 21
Deficiencies (21)
| Description | Severity |
|---|---|
| Resident R27's urinary catheter bag was left uncovered and visible to others on multiple occasions, violating dignity and privacy expectations. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R65's personal belongings were removed without permission and without involving the resident in care planning, violating resident self-determination rights. | Level of Harm - Minimal harm or potential for actual harm |
| Facility mail delivery was delayed on Saturdays until Monday afternoon, affecting all 93 residents' timely access to mail. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R3's advance directive documentation was inconsistent and contradictory, causing confusion about code status. | Level of Harm - Minimal harm or potential for actual harm |
| Residents R5, R34, and R65 had unclean and unsafe room environments including dirty heat registers, windows, and peeling flooring. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R59 reported physical abuse by CNA-FF which was not reported to administration and the alleged abuser continued to work for a week after the allegation. | Level of Harm - Minimal harm or potential for actual harm |
| Allegation of abuse for resident R59 was not reported to Nursing Home Administrator, state agency, or law enforcement as required. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not thoroughly investigate the abuse allegation reported by resident R59. | Level of Harm - Minimal harm or potential for actual harm |
| Residents R33, R46, R53, and R10 had inaccurate Minimum Data Set (MDS) assessments, including failure to document behavioral symptoms and PASARR Level 2 evaluations. | Level of Harm - Minimal harm or potential for actual harm |
| Residents R15, R16, R24, R27, R34, R81, and R6 did not receive showers at least weekly as per facility policy and care plans. | Level of Harm - Minimal harm or potential for actual harm |
| Residents R15, R16, and R27 were observed not wearing physician-ordered compression stockings with no documentation of refusal. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R34 did not receive ordered treatment for a venous stasis ulcer and had delayed provision of an air mattress. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R8 had an unwitnessed fall in the bathroom and neurological checks were not completed as per facility policy. | Level of Harm - Minimal harm or potential for actual harm |
| Residents R8, R24, and R81 did not have fall prevention interventions consistently implemented, including supervision, call light accessibility, fall mats, and body pillows. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R9 was not provided pain management consistent with professional standards, resulting in untreated pain and an emergency room visit. | Level of Harm - Minimal harm or potential for actual harm |
| Facility medication carts contained insulin vials and pens that were not labeled, not dated when opened, and/or expired. | Level of Harm - Minimal harm or potential for actual harm |
| Residents R24, R27, and R81 had enabler bars in use without documented quarterly reassessment of risks, benefits, and consent. | Level of Harm - Minimal harm or potential for actual harm |
| Residents R3, R1, R16, R24, R27, R34, R5, and R53 with wounds, indwelling devices, or feeding tubes were not placed on Enhanced Barrier Precautions (EBP) as required, and staff did not wear appropriate PPE during care. | Level of Harm - Minimal harm or potential for actual harm |
| The sink in the contaminated laundry area was not functional for 1-2 weeks, forcing staff to leave the contaminated area to wash hands, increasing infection risk. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R53 developed a facility-acquired pressure injury that was incorrectly staged and treated, with delayed treatment changes and incomplete care plan updates. | Level of Harm - Minimal harm or potential for actual harm |
| Residents R15 and R16 reported and were observed to have flies in their rooms, and flies were observed throughout the facility including dining areas and kitchen. Pest control was not consistently provided. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents: 93
Deficiency count: 21
Staffing rating: 1
MDS BIMS score: 12
MDS BIMS score: 13
MDS BIMS score: 13
MDS BIMS score: 15
MDS BIMS score: 5
MDS BIMS score: 15
Fall risk score: 8
Fall risk score: 16
Braden Scale score: 16
Braden Scale score: 14
Pressure injury size: 2
Pressure injury size: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA-FF | Certified Nursing Assistant | Named in abuse allegation and investigation |
| UM-D | Unit Manager | Named in abuse allegation investigation and grievance handling |
| NHA-A | Nursing Home Administrator | Named in abuse allegation investigation and multiple findings |
| DON-B | Director of Nursing | Named in abuse allegation investigation and multiple findings |
| SW-J | Social Worker | Named in resident belongings removal and abuse allegation investigation |
| NT-BB | Nurse Technician | Named in resident belongings removal and abuse allegation investigation |
| OT-GG | Occupational Therapist | Named in abuse allegation investigation and grievance assistance |
| LPN-G | Licensed Practical Nurse | Named in abuse allegation investigation and fall incident |
| CNA-L | Certified Nursing Assistant | Named in abuse allegation investigation |
| DON-B | Director of Nursing | Named in infection control and wound care findings |
| UM-E | Unit Manager | Named in infection control and wound care findings |
| UM-C | Unit Manager | Named in infection control and wound care findings |
| LPN-R | Licensed Practical Nurse | Named in infection control and wound care findings |
| CNA-X | Certified Nursing Assistant | Named in infection control and catheter care findings |
| CNA-Y | Certified Nursing Assistant | Named in infection control and catheter care findings |
| LPN-II | Licensed Practical Nurse | Named in infection control and feeding tube care findings |
| HM-T | Housekeeping Manager | Named in laundry and infection control findings |
| LS-U | Laundry Staff | Named in laundry and infection control findings |
| DM-RR | Dietary Manager | Named in food service and pest control findings |
| NHA-A | Nursing Home Administrator | Named in multiple findings and interviews |
Inspection Report
Routine
Deficiencies: 12
Aug 13, 2025
Visit Reason
The facility was surveyed for compliance with healthcare regulations including resident rights, care, safety, infection control, and environmental standards.
Findings
The survey identified multiple deficiencies including failure to ensure resident dignity, self-determination, safe and clean environment, protection from abuse, timely reporting of abuse, adequate assistance with activities of daily living, appropriate care and treatment, fall prevention, infection control, food service compliance, staffing data accuracy, and pest control.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure dignity and respect for residents with indwelling catheters, including failure to cover catheter bags in privacy bags. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to promote and facilitate resident self-determination through support of resident choice, including unauthorized removal of resident belongings. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a safe, clean, comfortable, and homelike environment, including dirty rooms, peeling flooring, and disconnected air conditioning/heating units. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect residents from physical abuse; an allegation of rough care by a CNA was not reported and the CNA continued to work. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse to the Nursing Home Administrator, state agency, and law enforcement as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary assistance with activities of daily living, including failure to provide weekly showers as scheduled for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate care and treatment, including failure to apply physician-ordered compression stockings, delayed wound treatment, and failure to perform neurological checks after a fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision and assistance to prevent accidents, including leaving a resident alone in the bathroom despite transfer status requiring assistance of two. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement an effective infection prevention and control program, including failure to implement Enhanced Barrier Precautions for residents with wounds, indwelling devices, or MDROs, and lack of functional hand hygiene sink in contaminated laundry area. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure menus were followed and served as posted, and failure to follow resident food preferences. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to accurately submit mandatory staffing information to CMS based on payroll data, resulting in an inaccurate one-star staffing rating. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an effective pest control program, resulting in numerous flies throughout the facility including resident rooms, dining areas, and kitchen. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 7
Residents affected: 5
Residents affected: 3
Residents affected: 93
Residents affected: 2
Residents affected: 93
Residents affected: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA-FF | Certified Nursing Assistant | Named in physical abuse allegation and failure to report abuse |
| UM-D | Unit Manager | Involved in abuse allegation follow-up and wound care |
| NHA-A | Nursing Home Administrator | Involved in multiple findings including abuse reporting, infection control, and staffing |
| DON-B | Director of Nursing | Involved in multiple findings including abuse reporting, infection control, and staffing |
| OT-GG | Occupational Therapist | Assisted resident with grievance related to abuse allegation |
| CNA-L | Certified Nursing Assistant | Reported abuse allegation and concerns about CNA-FF |
| LPN-G | Licensed Practical Nurse | Reported abuse allegation and fall care |
| NT-BB | Nurse Technician | Reported abuse allegation and fall care |
| DM-RR | Dietary Manager | Reported issues with meal preference slips and kitchen conditions |
| HM-T | Housekeeping Manager | Reported laundry sink issue and laundry process |
| MD-F | Maintenance Director | Reported freezer issues and laundry sink repair |
Inspection Report
Routine
Deficiencies: 1
Jun 26, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection prevention and control protocols, specifically related to the use of personal protective equipment during pressure ulcer dressing changes.
Findings
The facility failed to ensure staff donned appropriate personal protective equipment (PPE) during a pressure ulcer dressing change for one resident, which posed a risk for cross contamination and infection. Observation and interviews confirmed staff did not wear gowns as required by facility policy during the dressing change.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff donned appropriate PPE during pressure ulcer dressing change, risking cross contamination and infection. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA)5 | Observed not wearing gown during dressing change | |
| Licensed Practical Nurse (LPN)1 | Observed not wearing gown during dressing change and confirmed PPE requirements | |
| Director of Nursing (DON)/Infection Preventionist (IP) | Interviewed and confirmed expectation for staff to wear gown during dressing changes |
Inspection Report
Routine
Deficiencies: 7
May 8, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, dialysis care, pharmaceutical services, medication availability, staffing in dietary services, menu compliance, and food safety in the facility.
Findings
The facility failed to assess residents for safe self-administration of medications, ensure proper documentation and communication for dialysis care, maintain medication availability leading to missed doses for several residents, designate a dietary manager during a vacancy, follow approved menus and substitutions, and maintain sanitary food storage and preparation conditions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to assess two residents for safe self-administration of medications left at bedside. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure documentation of pre- and post-dialysis assessments and communication with dialysis center for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have medications available to administer as ordered for three residents, resulting in missed doses. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure one resident was free from significant medication errors due to unavailable medications and missed administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to employ a designated Dietary Manager during a vacancy period. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure menus and menu extensions were followed, including approved food substitutions and recipe adherence. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain kitchen in sanitary condition including proper labeling, dating, and storage of food. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for medication availability: 18
Residents affected by medication availability deficiency: 3
Residents affected by dietary manager vacancy: 89
Residents affected by menu and food safety deficiencies: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pharmacist 2 | Pharmacist | Provided detailed information on medication orders, deliveries, and insurance issues related to medication availability |
| RN2 | Registered Nurse and Unit Manager | Discussed medication ordering and availability issues |
| LPN2 | Licensed Practical Nurse | Reported on medication administration and reordering processes |
| LPN6 | Licensed Practical Nurse | Reported on medication reordering and pharmacy delivery issues |
| ADON | Assistant Director of Nursing | Provided information on medication refusal, communication with dialysis, and medication ordering challenges |
| DON | Director of Nursing | Discussed expectations for medication administration, communication, and oversight |
| Physician 1 | Physician | Expressed concerns about medication availability and significant medication errors |
| Dietary Manager | Dietary Manager | Discussed kitchen oversight and sanitation issues |
| DA1 | Dietary Aide | Reported on absence of dietary manager |
| Cook1 | Cook | Reported on absence of dietary manager and kitchen conditions |
| LPN9 | Licensed Practical Nurse | Reported on medication availability and ordering for resident R18 |
Inspection Report
Routine
Deficiencies: 1
Jan 30, 2025
Visit Reason
The inspection was conducted to review the facility's compliance with documentation standards for medication administration and treatments as ordered by physicians, focusing on four residents' medical records.
Findings
The facility failed to ensure proper documentation of care and services for four residents, including medication administration and treatments, which could lead to delays in treatment or medication. Missing documentation was confirmed by the Director of Nursing during the inspection.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to document medication administration and treatments for residents as ordered by the physician. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed missing documentation of medications and treatments on the MAR and TAR during interview. |
Inspection Report
Routine
Deficiencies: 10
Oct 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication management, infection control, grievance handling, and safety measures.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of treatment changes, inadequate grievance investigation and resolution, delayed reporting of abuse allegations, incomplete discharge summaries, medication errors, improper infection control practices, and failure to provide ordered treatments and care according to professional standards.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to notify resident representative when occupational and physical therapy were discontinued. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to promptly resolve resident grievances and lack of thorough grievance investigations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report allegations of abuse and incomplete investigations into abuse allegations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a complete discharge summary and medication list for a discharged resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide treatment and care according to orders and professional standards, including failure to apply tubi grips and inadequate wound care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision during resident transfer using a Hoyer lift, creating potential unsafe transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate food items for a resident on a renal/LCS diet, including serving high potassium foods. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary respiratory care by not changing the HME trach valve daily as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Medication errors including incorrect transcription of medication orders, administration of crushed delayed release medication, administration of medications outside scheduled times, and unlabeled glucose monitoring device. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain infection prevention and control practices, including inadequate hand hygiene during tracheostomy and incontinence care for a resident on contact isolation for C. difficile. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 20
Medication errors for R3: 69
Residents affected by grievance issue: 5
Residents affected by abuse reporting issue: 2
Residents affected by infection control issue: 1
Residents affected by medication error issue: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN-S | Registered Nurse | Did not immediately report allegation of abuse from resident R10 |
| LPN-M | Licensed Practical Nurse | Did not change HME trach valve daily as ordered for R3; administered medications incorrectly |
| RN-L | Registered Nurse | Administered crushed delayed release medication to R14; did not report medication errors timely |
| DON-B | Director of Nursing | Acknowledged medication errors and failure to follow infection control; involved in grievance and medication order review |
| NHA-A | Nursing Home Administrator | Notified of multiple deficiencies including medication errors, grievance issues, and infection control lapses |
| DOR/COTA-Q | Director of Rehab/Certified Occupational Therapy Assistant | Unable to provide documentation of notification to POA for therapy discontinuation |
| Unit Manager-I | Unit Manager | Involved in antibiotic stewardship education and medication order review |
| Medical Records/Central Supply-J | Medical Records/Central Supply Staff | Responsible for ordering supplies including trach supplies; did not order HME trach valve |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 6, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide medically related social services to assist a resident (R1) in consenting to sexual relations with her spouse.
Findings
The facility did not ensure that R1, who is severely cognitively impaired and confused at times, was assessed for her ability to consent to sexual relations on 5/18/24 despite prior knowledge of her spouse's intentions. Documentation was lacking for a formal assessment of consent, and the social worker admitted to not completing a formal assessment. Nursing notes documented R1 as alert and orientated x2 after intimate time with her husband, but no formal consent assessment was found.
Complaint Details
The complaint investigation focused on whether the facility ensured R1's ability to consent to sexual relations with her spouse on 5/18/24. The social worker did not complete a formal assessment, and no documentation was found to support that R1 was able to consent. The social worker assumed consent based on a conversation with R1 but did not document a formal assessment. Nursing staff documented R1 as alert and orientated x2 after intimate time with her husband. The facility failed to provide medically related social services to assist R1 in consenting.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide medically related social services to help resident R1 achieve or maintain mental and psychosocial health related to consent for sexual relations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for potential sexual abuse: 3
BIMS score: 0
Dates of nursing notes: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON-B was informed of findings and involved in discussions about the assessment of R1's consent. | |
| Social Worker | SW-D spoke with R1 on 5/18/24, did not complete a formal assessment of consent, and was involved in discussions with the surveyor. | |
| Nursing Home Administrator | NHA-A was informed of the findings on 6/6/24. |
Inspection Report
Routine
Census: 74
Deficiencies: 15
May 14, 2024
Visit Reason
Routine inspection of Burlington Health and Rehabilitation Center to assess compliance with regulatory requirements including resident rights, abuse reporting, specialized services, care planning, medication management, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to provide prior written notice for room changes to residents and their representatives, delayed reporting of abuse allegations, failure to incorporate PASARR recommendations into care planning, incomplete baseline care plans, improper hearing aid management, inadequate pressure ulcer care, incomplete bowel and bladder incontinence assessments and care, improper feeding tube care, lack of dialysis communication, missing assessments and consents for bed rails/enabler bars, medication administration delays and errors, improper labeling and storage of insulin, failure to coordinate hospice services, unsafe food handling practices, and inadequate infection prevention measures.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Actual harm: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to provide prior written notice and obtain consent for room changes for 6 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse and neglect incidents to the State Survey Agency for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to incorporate PASARR Level 2 recommendations into resident's assessment and care planning for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Incomplete baseline care plan within 48 hours of admission for 1 resident, missing enabler bar usage. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure proper treatment and use of hearing aids for 1 resident, including missing documentation and hearing aids not worn. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and offloading for 1 resident with multiple pressure injuries. | Level of Harm - Actual harm |
| Failure to provide appropriate care and assessment for bowel and bladder incontinence for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure appropriate care and monitoring of feeding tube for 1 resident, including unlabeled flush bags and uncalibrated feeding pump. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide dialysis services consistent with professional standards and failure to complete dialysis communication forms for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to assess, obtain informed consent, and document risks and benefits prior to installation of bed rails/enabler bars for 7 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to administer medications within prescribed timeframes resulting in delayed administration of morning medications for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to label insulin vials with open dates and remove expired insulin pens from medication carts affecting 4 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to coordinate hospice services including missing physician certification, orders, documentation of visits, and designated facility liaison for 1 resident receiving hospice care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement infection prevention measures including improper medication handling by nurse and catheter bags placed on or touching the floor for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to distribute and serve food in a manner that prevents foodborne illness; staff observed handling ready to eat food with contaminated gloves and poor hand hygiene. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected by room change notice deficiency: 6
Residents affected by abuse reporting deficiency: 2
Residents affected by PASARR deficiency: 1
Residents affected by incomplete baseline care plan: 1
Residents affected by hearing aid deficiency: 1
Residents affected by pressure ulcer care deficiency: 1
Residents affected by bowel/bladder incontinence deficiency: 1
Residents affected by feeding tube care deficiency: 1
Residents affected by dialysis communication deficiency: 1
Residents affected by bed rail assessment and consent deficiency: 7
Residents affected by medication administration timing deficiency: 2
Residents affected by insulin labeling deficiency: 4
Residents affected by hospice coordination deficiency: 1
Residents affected by infection prevention deficiency: 2
Residents affected by food safety deficiency: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN-F | Licensed Practical Nurse | Observed dispensing medications into bare hands and administering late medications. |
| DON-B | Director of Nursing | Provided education on side rails, acknowledged insulin labeling issues, and discussed medication timing. |
| RN Consultant-C | Registered Nurse Consultant | Reported lack of dialysis communication forms and pharmacy follow-up issues. |
| Cook-K | Cook | Observed handling ready to eat food with contaminated gloves. |
| Dietary Aide-M | Dietary Aide | Observed wiping nose with gloves while handling food without changing gloves or washing hands. |
| RN-E | Registered Nurse | Confirmed missing hearing aids and improper medication labeling. |
| NHA-A | Nursing Home Administrator | Informed of multiple deficiencies including medication timing, dialysis communication, and hospice coordination. |
Inspection Report
Complaint Investigation
Deficiencies: 2
May 8, 2024
Visit Reason
The inspection was conducted due to complaints and self-reports regarding delayed reporting of suspected abuse, neglect, or theft incidents and concerns about pressure ulcer care for residents.
Findings
The facility failed to timely report two incidents of alleged misappropriation and resident-to-resident altercation to the State Survey Agency within 5 working days. Additionally, the facility did not ensure appropriate pressure ulcer care for one resident (R13), including failure to implement care plan interventions such as offloading the heel, resulting in actual harm.
Complaint Details
The complaint investigation involved allegations of delayed reporting of suspected misappropriation of $60 from resident R322 and a resident-to-resident altercation involving resident R47. The facility did not report these incidents to the State Survey Agency within the required 5 working days. The investigation also included review of pressure ulcer care for resident R13, who developed a facility-acquired pressure injury that was not properly managed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Actual harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including not implementing care plan interventions for offloading and wound management. | Level of Harm - Actual harm |
Report Facts
Amount misappropriated: 60
Number of facility reported incidents not timely reported: 2
Pressure injury measurements: 2.5
Pressure injury measurements: 3.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NHA-A | Nursing Home Administrator | Interviewed regarding delayed reporting of incidents and facility reporting procedures |
| DON-B | Director of Nursing | Involved in wound care oversight and discussions regarding pressure injury staging and citation disagreement |
| RN Consultant-C | Registered Nurse Consultant | Reviewed resident R13's medical record and provided expert opinion on wound care |
| ADON-J | Assistant Director of Nursing | Observed wound care for resident R13 |
| RN/MDS Coordinator-D | Registered Nurse/Minimum Data Set Coordinator | Reported prior Director of Nursing and commented on offloading issues |
Inspection Report
Complaint Investigation
Deficiencies: 5
Nov 2, 2023
Visit Reason
The inspection was conducted due to allegations of abuse involving Resident R32 and concerns about behavioral health care for residents R2, R4, R5, and R32.
Findings
The facility failed to timely report an allegation of abuse involving R32, did not thoroughly investigate the abuse allegation, and did not ensure that residents R2, R4, R5, and R32 received necessary behavioral health care including proper care planning, substance abuse evaluation interpretation, and medication management. Resident R2 experienced withdrawal symptoms and an overdose due to lack of coordination of care and medication management. The facility also failed to provide accurate and complete 30-day discharge notices to residents R2 and R4.
Complaint Details
The complaint investigation was triggered by an allegation of abuse involving Resident R32, including failure to report the allegation timely and failure to investigate thoroughly. Additional concerns involved behavioral health care deficiencies for residents R2, R4, R5, and R32.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Respond appropriately to all alleged violations including thorough investigation of abuse allegations. | Level of Harm - Minimal harm or potential for actual harm |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Level of Harm - Minimal harm or potential for actual harm |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Level of Harm - Immediate jeopardy to resident health or safety |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Deficiencies cited: 5
Days medication not received: 8
30-day discharge notices: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN-E | Licensed Practical Nurse | Named in relation to abuse allegation involving R32 and R4, including documentation of incidents and communication failures. |
| DON-B | Interim Director of Nursing | Involved in abuse allegation investigation and communication with staff regarding R32 and R4. |
| SSD-C | Social Services Director | Interviewed regarding abuse allegations and behavioral health care for residents. |
| SW-D | Social Worker | Interviewed regarding abuse allegations and behavioral health care for residents. |
| NHA-A | Nursing Home Administrator | Informed of immediate jeopardy and involved in discussions about behavioral health care deficiencies. |
| RNC-H | Registered Nurse Consultant | Involved in discussions about behavioral health care deficiencies. |
| CS-I | Clinical Specialist | Involved in discussions about behavioral health care deficiencies and care plan updates. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 123
Deficiencies: 10
Sep 14, 2023
Visit Reason
Complaint investigation triggered by allegations of resident abuse, substance use, and failure to provide appropriate care and supervision.
Findings
The facility failed to protect residents from abuse including sexual abuse by an employee, did not ensure timely reporting and investigation of abuse allegations, failed to provide adequate supervision to prevent substance use and overdoses, did not maintain accurate and accessible code status documentation, and did not provide necessary behavioral health care and services for residents with substance use disorders.
Complaint Details
Complaint investigation involved allegations of resident abuse including sexual abuse by an employee, failure to report and investigate abuse, failure to provide adequate supervision to prevent substance use and overdoses, failure to maintain accurate code status documentation, and failure to provide necessary behavioral health care and services. Immediate jeopardy was identified related to sexual abuse and failure to provide basic life support, later removed after corrective actions.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 3
Level of Harm - Actual harm: 1
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (10)
| Description | Severity |
|---|---|
| Resident employed by the facility without appropriate care plan or job description, with a history of abuse and substance use. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to promptly consult physician for significant changes in condition for a resident with substance abuse history. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect a resident from sexual and mental abuse by a dietary aide who engaged in a personal/sexual relationship and provided illegal drugs. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to timely report suspected abuse and results of investigations to proper authorities for multiple incidents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond appropriately to alleged violations including delayed and incomplete investigations of abuse and misappropriation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide basic life support and follow facility policies for code status and emergency response, resulting in unclear code status and delayed CPR. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure environment free from accident hazards and provide adequate supervision to prevent accidents, including failure to monitor residents with substance use disorder to prevent overdoses and elopement. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to observe nurse aides' job performance and provide regular training, including lack of performance reviews for multiple CNAs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary behavioral health care and services to residents with substance use disorders, including lack of assessment, counseling, and effective care planning. | Level of Harm - Actual harm |
| Failure to conduct and document a facility-wide assessment to determine resources necessary to care for residents competently, including those with substance use disorders. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 97
Total licensed capacity: 123
Number of overdoses: 4
Number of overdoses: 4
Number of CNAs without recent performance review: 5
Number of residents with substance use disorder: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DA-O | Dietary Aide | Engaged in sexual relationship with resident R10, provided illegal drugs, and failed to maintain caregiver boundaries. |
| NHA-A | Nursing Home Administrator | Interviewed DA-O about relationship with R10 and R1, aware of abuse but failed to intervene appropriately. |
| DON-B | Director of Nursing | Involved in interviews and investigations related to resident care, code status, and abuse allegations. |
| HR-E | Human Resources Manager | Interviewed regarding employment and job duties of resident R1. |
| MM-F | Maintenance Manager | Interviewed regarding work duties of resident R1. |
| RN-KK | Registered Nurse | Responded to resident R1's unresponsive state, called 911, but did not initiate CPR or overhead code blue. |
| LPN-NN | Licensed Practical Nurse | Responded to resident R1's unresponsive state, assisted RN-KK, but did not initiate overhead code blue. |
| SWA-H | Social Worker Assistant | Involved in care planning and investigation of resident R11's substance use disorder. |
| Medical Director -AA | Medical Director | Interviewed regarding facility's handling of residents with substance use disorders. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Mar 21, 2023
Visit Reason
The inspection was conducted based on complaints and self-reports involving allegations of sexual abuse, failure to report suspected abuse and neglect, failure to investigate allegations, inadequate care related to pressure injuries, falls, nutrition, and hydration.
Findings
The facility failed to protect residents from sexual abuse, did not timely report and investigate allegations of abuse and neglect, failed to provide appropriate care for pressure injuries, falls, and nutritional needs, and did not ensure adequate supervision and use of assistive devices to prevent accidents.
Complaint Details
The complaint investigation involved multiple residents with allegations of sexual abuse, failure to report abuse and neglect, failure to investigate allegations, inadequate care for pressure injuries, falls, and nutritional issues. The facility was found deficient in multiple areas related to resident safety and care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to protect residents from sexual abuse and failure to assess residents' ability to consent to sexual activity. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse, neglect, or theft and failure to report investigation results to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond appropriately to all alleged violations and failure to submit investigations timely to the state agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, including failure to provide ordered daily showers. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to obtain doctor's order and care plan for splint use resulting in Stage 4 pressure injury with exposed tendon. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, including failure to follow care plans for falls and use assistive devices. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide enough food/fluids to maintain residents' health, including failure to assess fluid needs and weight loss interventions. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 2
Weight loss percentage: 10.3
Weight loss percentage: 6.67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SW-E | Social Worker | Assisted with sexual abuse investigation and relationship assessments for residents R23 and R76 |
| NHA-A | Nursing Home Administrator | Involved in multiple investigations and exit meetings |
| DON-B | Director of Nursing | Involved in multiple investigations and exit meetings |
| RNC-G | Regional Nurse Consultant | Involved in sexual abuse investigation and exit meetings |
| LPN-N | Licensed Practical Nurse | Assessed resident R61 after fall incident |
| Dietician-W | Dietician | Conducted nutritional assessments for residents R17 and R262 |
| OT-Q | Occupational Therapist | Provided therapy and recommendations for resident R7's hand splint |
| LPN-J | Licensed Practical Nurse | Interviewed regarding fall prevention for resident R463 |
Inspection Report
Complaint Investigation
Deficiencies: 13
Mar 21, 2023
Visit Reason
The inspection was conducted based on complaints and self-reports involving allegations of sexual abuse, inadequate employee background checks, failure to report abuse and neglect, failure to investigate allegations, falls, pressure injury care, nutrition and hydration concerns, antibiotic stewardship, infection prevention, and vaccination documentation.
Findings
The facility was found deficient in multiple areas including failure to protect residents from sexual abuse, inadequate employee background screening, failure to timely report and investigate abuse and neglect, inadequate pressure injury prevention and care, failure to follow care plans for fall prevention, improper nutrition and hydration management, inappropriate antibiotic use, incomplete infection prevention program including water management, improper food storage, and incomplete vaccination documentation.
Complaint Details
The complaint investigation involved allegations of sexual abuse between residents, inadequate employee background checks, failure to report and investigate abuse and neglect, falls, pressure injury care, nutrition and hydration concerns, antibiotic stewardship, infection prevention, and vaccination documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to protect residents from sexual abuse including lack of assessment for consent and inadequate supervision. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete required caregiver and criminal background checks for employees prior to employment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse, neglect, or theft to proper authorities and failure to investigate allegations thoroughly. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond appropriately to allegations of neglect and submit investigations timely to the state agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide treatment and care according to orders, including failure to provide daily showers as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers, including failure to obtain doctor's orders and care plans for splints leading to Stage 4 pressure injury with exposed tendon. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure adequate supervision and use of assistive devices to prevent accidents, including falls due to non-adherence to care plans. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide enough food and fluids to maintain residents' health, including failure to assess fluid needs and delayed nutritional interventions for significant weight loss. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure antibiotic protocols were used to prevent unnecessary administration of antibiotics to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to conduct and document a facility-wide assessment to determine necessary resources for competent care during day-to-day operations and emergencies, including lack of infection preventionist staffing and incomplete emergency preparedness and water management plans. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to procure food from approved sources and store food in accordance with professional standards, including food stored on freezer floor, ice buildup, and improper storage of resident brought-in food. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, including ineffective water management plan and failure to disinfect wound care scissors between uses. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement policies and procedures for flu and pneumonia vaccinations, with missing documentation of vaccine administration or refusal for several residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for antibiotic usage: 19
Residents reviewed for immunizations: 5
Residents reviewed for psychotropic medication: 5
Residents reviewed for falls: 6
Residents reviewed for pressure injuries: 6
Residents reviewed for nutrition and hydration: 7
Residents affected by sexual abuse incident: 2
Employees with incomplete background checks: 3
Boxes of food observed on freezer floor: 18
Residents with pressure injury measurements: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator-A | Nursing Home Administrator | Named in relation to multiple findings including sexual abuse investigation, employee background checks, abuse reporting, infection prevention, and facility assessment. |
| Director of Nursing-B | Director of Nursing | Named in relation to multiple findings including sexual abuse investigation, employee background checks, abuse reporting, infection prevention, and facility assessment. |
| Social Worker-E | Social Worker | Involved in sexual abuse investigation and reporting. |
| Regional Nurse Consultant-G | Regional Nurse Consultant | Involved in sexual abuse investigation, infection prevention, and facility assessment. |
| LPN-J | Licensed Practical Nurse | Named in relation to incomplete background checks and fall incident. |
| CNA-AA | Certified Nursing Assistant | Named in relation to incomplete background checks. |
| CNA-BB | Certified Nursing Assistant | Named in relation to incomplete background checks. |
| LPN-N | Licensed Practical Nurse | Named in relation to fall incident involving R61. |
| LPN-O | Licensed Practical Nurse | Observed providing wound care to R7. |
| Dietician-W | Dietician | Named in relation to nutritional assessments and interventions. |
| Nurse Practitioner | Ordered occupational therapy for R7. | |
| Unit Manager LPN J | Licensed Practical Nurse Unit Manager | Named in relation to infection preventionist training and fall prevention. |
| Activity Director-M | Activity Director | Responsible for checking resident refrigerator daily. |
| LPN I | Licensed Practical Nurse | Observed performing wound care and improper disinfection of scissors. |
| Regional Nurse Consultant-G | Regional Nurse Consultant | Interviewed regarding psychotropic medication monitoring. |
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