Abbotsford Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Abbotsford, Wisconsin.
- Location
- 600 E Elm St, Abbotsford, Wisconsin 54405
- CMS Provider Number
- 525435
- Inspections on file
- 28
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Abbotsford Health Care Center during CMS and state inspections, most recent first.
A resident with intact cognition reported missing money after a hospital stay, stating $200 was gone while staff had only verified seeing $50 in the room. The facility’s investigation included interviewing the resident, searching for the money, contacting law enforcement, and interviewing staff, but it could not confirm the total amount missing beyond the $50 observed. Although the facility’s abuse/exploitation policy required interviewing all involved persons and providing staff training with demonstrated competency, there was insufficient evidence that residents were systematically interviewed about missing items or that staff received timely misappropriation education, and other residents did not recall being questioned about missing belongings.
A resident was accepted for admission from a hospital with the understanding that she was a pivot transfer, but upon arrival she was placed in a too-small wheelchair, slid to the floor when reaching down, and was sent to the ED by EMS because staff could not get her up. The facility’s record contained only pre-admission documents and lacked admission notes, assessments, incident documentation, or discharge records. Leadership acknowledged that no admission paperwork was completed and that the facility lacked appropriate bariatric equipment, yet there was no documented assessment of transfer status, no evidence that the resident or representative received required written transfer/discharge notices, appeal rights, Ombudsman contact information, or bed-hold and return-rights information, and no documented communication with the hospital explaining the reason for discharge or confirming re-admission.
A resident with severe cognitive impairment, history of falls, and documented wandering and elopement risk was care planned to have a Wanderguard and redirection from doors, but surveyors observed the resident without a Wanderguard or chair alarm and independently leaving the room and entering another resident’s room before staff intervened. Staff confirmed the resident was supposed to always wear a Wanderguard, yet could not account for how long it had been off, including around the time of a recent fall and ED visit, and there was no documentation of assessments or routine checks to ensure the device was in place, despite facility policies requiring elopement assessment, care planning, and implementation of accident-prevention interventions.
Two residents did not receive proper skin assessments and wound documentation as required by professional standards. One resident with a surgical incision did not have assessments or documentation of the wound site, including after the removal of steri strips and an episode of bleeding. Another resident with multiple comorbidities and a new heel wound did not receive a comprehensive initial wound assessment, with missing documentation of wound size and delayed follow-up.
A resident admitted with an unstageable pressure injury to the left heel did not receive a comprehensive PI assessment, including measurements and description, upon admission. The initial assessment only noted the presence of the PI, and a detailed wound assessment was not completed until several days later by the wound clinic. The DON confirmed that a complete assessment was expected but not documented.
A resident with moderate cognitive impairment and a history of wandering left the facility without staff authorization after independently arranging transportation. Although the care plan noted the guardian's permission for the resident to leave for smoking, no new interventions or monitoring were added following the incident, despite facility policy requiring updates to care provision after such events.
A resident with mild cognitive impairment and a history of wandering left the facility without staff knowledge or authorization after independently arranging transport, despite care plan requirements for supervision. The facility lacked documentation of sign-out procedures, did not complete a thorough investigation, and failed to educate staff on elopement protocols following the incident.
The facility did not complete required background checks for an employee before hire, as mandated by its abuse prevention policy. Due to miscommunication between the facility and corporate office, the employee began working without a Background Information Disclosure, DOJ response, or Government Findings report, and was observed in resident care areas despite the lack of screening.
A resident with multiple diagnoses and intact cognition had side rails removed from her bed after a hospital stay, but the care plan was not updated to reflect this change. Despite audits indicating updates, the care plan continued to list side rails as an intervention, and the resident did not receive an alternative assistive device as discussed. The DON confirmed the removal was per protocol and that side rails would not improve mobility, but the care plan was not revised accordingly.
The facility did not have a director of food and nutrition services who met the minimum qualification requirements, as the current Dietary Manager is still completing the necessary certification program. Additionally, there is no full-time Registered Dietician on staff, with the RD only present one to two days per week. This deficiency could potentially impact all residents in the facility.
Surveyors observed improper food handling and storage practices, including stacking wet dishes, unsanitary handwashing sinks, and unlabeled or undated food items in refrigerators and freezers. Staff acknowledged these actions did not meet facility policies or food safety standards.
Surveyors found widespread frayed carpeting, stained floors, and damaged walls throughout the facility, with staff unable to identify the causes of carpet spots or provide documentation of follow-up. The Maintenance Director reported limited cleaning and maintenance, and the DON confirmed the issues had persisted for an extended period. These deficiencies affected all areas used by residents, staff, and visitors.
Two residents did not have complete, person-centered care plans: one lacked documented accommodations for vision and hearing deficits during activities and had no assessment or interventions for meal preferences, while another did not have a safe smoking plan in place despite being observed smoking unsupervised and having physical limitations. Staff interviews and record reviews confirmed these omissions.
A resident with diabetes and chronic wounds did not receive consistent wound care, as treatment orders from the wound clinic were not promptly transcribed or implemented, nutritional and zinc supplement recommendations were missed, and a protective boot was not applied as ordered. Documentation and monitoring of wound care were incomplete, and staff interviews revealed confusion about order follow-through, resulting in gaps in necessary treatment and services to promote wound healing.
Surveyors observed two residents for whom infection control protocols were not followed: a resident's catheter bag was repeatedly seen dragging on the floor while attached to a wheelchair, and during a dressing change for another resident, clean gauze and a measuring tool were contaminated by contact with the floor and then used in the procedure. Both the infection preventionist and DON confirmed these practices did not meet facility expectations.
A facility failed to ensure the safety of mechanical lifts and proper sling size determination, leading to an incident where a resident was injured during a transfer. Staff were unaware of how to select the correct sling size, and maintenance staff lacked training to inspect lift safety. The facility did not have a system for labeling sling sizes or a reference chart, contributing to potential risks for all residents using mechanical lifts.
A resident with dementia and a fall risk was injured during a Hoyer lift transfer when a CNA failed to follow the facility's policy requiring two staff members for such transfers. The CNA attempted the transfer alone, resulting in the resident slipping from the sling and sustaining severe head injuries. The incident highlighted a lack of adherence to established procedures and inadequate supervision during the transfer.
The Bedrock corporation governing body failed to maintain current payments with service providers, leading to service disruptions and potential risks to resident care. The facility's aging vendor report showed significant outstanding balances, some over three years old. The Nursing Home Administrator was unaware of past due amounts and payment statuses, indicating a lack of communication and oversight.
A resident with severe cognitive impairment and multiple medical conditions was sent to the hospital for emergency evaluation but faced a delay in returning to the facility due to confusion over transportation responsibilities. The facility and managed care organization were unclear about who should arrange transport, resulting in the resident staying overnight at the hospital. The facility's van service operates only during daytime hours, and alternative options were unavailable, highlighting a recurring issue in rural areas.
The facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and unmet resident needs. Observations and interviews revealed that residents waited extended periods for assistance, with staff overwhelmed by high acuity demands. Despite complaints, the administration did not effectively address staffing concerns, leading to ongoing deficiencies in care.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of a resident’s money and did not ensure required interviews were completed. One cognitively intact resident (BIMS 15/15) reported that $200 was missing after returning from the hospital, while staff had previously observed a $50 bill in the resident’s room the day before. The facility’s investigation included an interview with the resident, a search for the missing money that was not found, contact with law enforcement, and staff interviews. However, the amount of money allegedly missing could not be confirmed beyond the $50 observed by staff, and the resident continued to state that $200 was missing. The facility’s abuse/neglect/exploitation policy required identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, as well as training staff on changes made and demonstrating staff competency after training. During the survey, the Social Services Director stated that resident interviews were conducted through daily “Angel Rounds” and provided a blank Angel Rounds form and a typed list of 26 residents with yes/no responses regarding missing items, with only the involved resident reporting missing money. Other interviewed residents did not recall being interviewed about missing items or money. A CNA familiar with the incident reported not remembering any staff education or training related to misappropriation after the money was reported missing. The surveyor determined the facility did not complete a thorough investigation due to lack of evidence of resident interviews and lack of timely staff training on misappropriation.
Failure to Document Admission/Discharge and Provide Required Transfer, Appeal, and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with required transfer/discharge notices, appeal rights information, Ombudsman contact information, and written bed-hold and return-rights information, as well as failure to document the admission, fall, and discharge. A resident (R7) was accepted for admission from a referring hospital with the understanding that she was a pivot transfer. Upon arrival, she traveled approximately two hours and was placed in a wheelchair that was too small. Shortly after arrival, while seated in the wheelchair, she reached down to pick something up and slid from the chair onto the floor. EMS was called because staff were unable to get her up from the floor, and she was transported to the emergency room. The facility’s electronic record for the resident contained only pre-admission documents such as advance directives, hospital discharge summary, and insurance information, but no admission documentation, progress notes, assessments, incident reports, or discharge documentation. The facility’s Admissions Coordinator stated that the resident was not admitted to the facility and reported that the resident could not transfer as reported by the hospital, slid from the wheelchair, and was sent to the hospital via EMS. The Nursing Home Administrator, however, stated that the facility had accepted the resident as an admission and that no admission paperwork had been completed. The Administrator reported that therapy was asked to assess the resident’s transfer status, but before that occurred, the resident had already fallen from the wheelchair. The Administrator stated that the facility did not have the appropriate equipment, such as a bariatric hoyer lift or sling, to care for the resident when it was determined she could not pivot transfer. The facility did not provide evidence that the resident was assessed at the facility to determine her transfer status, nor did it provide documentation that the resident’s needs could not be met in the facility as required by its transfer/discharge policy. The facility did not provide evidence that the required transfer/discharge process was followed. There was no documentation that the resident or her representative received written notice of transfer or discharge, including the specific reason for transfer, effective date, location of transfer, appeal rights, or the name, address, phone number, and email of the State Long-Term Care Ombudsman. There was also no evidence that the resident or representative received written information on the facility’s bed-hold duration, reserve bed payment policy, or the right to return to the facility. The facility did not provide evidence of communication with the receiving hospital explaining the reason for the resident’s discharge or documenting agreement to re-admit the resident. Although the Administrator reported being told that a correct hoyer sling would be ordered for the resident, the facility did not provide evidence that such a sling was ordered. The facility was unable to provide evidence that its own transfer and discharge policy requirements were met for this resident. The surveyor’s review of communications showed only an email chain in which the Admissions Coordinator initially accepted the resident for admission and later informed the referring hospital that there were issues when the resident arrived, that she could not transfer as reported, and that she slid to the floor and was taken to the hospital by ambulance. No further communication with the hospital after the resident’s transfer was provided. A discharge summary from the receiving hospital documented follow-up needs related to deconditioning, weakness, ankle and knee instability, bariatric management, and UTI, but the facility did not produce any pre-admission assessment indicating the resident’s transfer status or any documentation that the discharge process, including notices and appeal information, was followed. Overall, the facility failed to document the resident’s admission, fall, and discharge and failed to provide the required notices and information related to transfer/discharge, appeal rights, Ombudsman contacts, and bed-hold and return policies.
Failure to Maintain Wanderguard and Supervision for Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of assistance devices to prevent accidents for one resident identified as an elopement risk. The resident had diagnoses including altered mental status, history of falling, alcohol dependence with withdrawal delirium, age-related physical debility, and metabolic encephalopathy, and an MDS BIMS score of 00 indicating severe cognitive impairment. The baseline care plan identified the resident as at risk for elopement related to wandering and specified interventions including a Wanderguard on the right wrist and redirection from doors. Facility policies on elopement and accidents/supervision required elopement risk assessment at admission, development of an elopement prevention care plan, use of an alarm system to notify staff when exit doors are opened, and implementation of specific interventions to reduce risk from environmental hazards, including adequate supervision. On the survey date, the NHA identified the resident as one of two residents using the Wanderguard system, but the surveyor observed the resident alone in a wheelchair without any Wanderguard device in place and speaking incoherently about needing to meet family. A CNA confirmed the resident was supposed to always have a Wanderguard but could not locate it, and an RN then placed a Wanderguard on the resident’s ankle, stating the resident had fallen the previous night and been sent to the ED, with no ability to determine how long the resident had been without the device. The surveyor later observed the resident independently exit the room at a fast walk, cross the hall, and enter another resident’s room without a chair alarm in place, requiring immediate staff intervention and redirection. Record review showed prior documentation of wandering and attempts to go through doors looking for beer, with a Wanderguard previously placed due to elopement risk, but there was no documentation regarding whether the Wanderguard was in place before or after the fall and ED visit, no documentation of assessment upon return, and no CNA or nursing documentation of routine monitoring to ensure the Wanderguard was in place. Staff interviews indicated reliance on a binder listing residents requiring Wanderguards and a shared responsibility among all staff interacting with the resident to ensure the device was in place.
Failure to Complete and Document Wound Assessments
Penalty
Summary
The facility failed to provide appropriate skin assessments and treatment in accordance with professional standards of practice for two residents. For one resident with multiple traumatic injuries and a surgical incision on the left upper extremity, staff did not assess or document the condition of the surgical site, nor did they document the removal of steri strips as ordered. There was no evidence of ongoing assessments of the surgical incision, despite a physician's order for dressing changes and a noted incident of partial dehiscence and bleeding at the site. For another resident with a history of chronic ulcer, diabetes, peripheral vascular disease, and recent amputation, staff did not complete a comprehensive wound assessment when a new wound was first identified. The initial documentation lacked details such as wound size, and there was a delay in completing a full assessment. The resident was later found to have a pressure ulcer on the left heel, but the facility did not have documentation of an initial assessment with measurements when the wound was first discovered.
Failure to Complete Comprehensive Pressure Injury Assessment on Admission
Penalty
Summary
A deficiency occurred when staff failed to implement professional standards of practice for pressure injury (PI) care and prevention for a resident admitted with an unstageable PI to the left heel. Upon admission, the resident had multiple diagnoses including hemiplegia, hemiparesis, MRSA infection, deep tissue damage to the left heel, diabetes mellitus, protein-calorie malnutrition, atrial fibrillation, chronic kidney disease, anxiety disorder, and depression. The resident was assessed as having intact cognition but required moderate to maximum assistance with activities of daily living and was identified as being at risk for pressure injuries. Despite the presence of a pressure injury on admission, staff did not complete a comprehensive PI assessment that included measurements and a detailed description of the wound. The initial clinical assessment only noted the existence of an unstageable PI without further specifics. The first documented wound assessment with measurements and description was not completed until several days after admission by the wound clinic. During an interview, the DON confirmed that there was no documented comprehensive admission assessment of the PI, despite acknowledging that such an assessment was expected.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to update a resident's care plan with new interventions or monitoring following an incident of unauthorized elopement. The resident, who was admitted under guardianship with diagnoses including benign neoplasm of meninges and mild cognitive impairment, had a BIMS score of 7, indicating moderate cognitive impairment, and a documented history of wandering and attempted elopement. The resident's care plan allowed for leaving the premises to smoke, as permitted by the guardian, but did not include specific interventions to address the risk of elopement despite the resident's known behaviors and history. On a specific date, the resident independently arranged for transportation and left the facility without staff authorization to attend an appointment that had been cancelled by the guardian. The facility's Director of Nursing confirmed that, although the guardian refused the use of a wander guard and Adult Protective Services were notified, no new interventions or monitoring were added to the care plan to prevent recurrence of such incidents. This lack of updated care planning was not in accordance with facility policy, which requires defining how care provision will be changed or improved to protect residents after such events.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Documentation
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents, resulting in a resident leaving the premises without staff knowledge or authorization. The resident, who was under guardianship and had diagnoses including mild cognitive impairment and a history of wandering and elopement, was permitted by their guardian to leave the facility to smoke, as the facility is smoke-free. Despite this, the resident's care plan required staff supervision due to confusion and altered mental status. On the day of the incident, the resident independently arranged for transport and left the facility to attend an appointment that had been previously canceled by the guardian, without signing out or informing staff. The facility's investigation into the incident was incomplete, as there was no documentation of resident or staff interviews, and no evidence that the resident had been signing out when leaving the premises. Staff members, including CNAs, reported not receiving education on elopement procedures following the incident, and the DON was unable to provide documentation of interventions implemented to prevent recurrence. The facility's policy required adequate supervision for residents at risk of elopement, but this was not followed in the case of this resident.
Failure to Screen Employee for Abuse and Neglect History Prior to Hire
Penalty
Summary
The facility failed to implement its policies and procedures regarding the screening of employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. Specifically, one of eight employees reviewed, identified as Intern D, was hired without the required Background Information Disclosure (BID), Department of Justice (DOJ) response, or Government Findings report being completed prior to starting work. The facility's policy mandates that all potential employees, including students affiliated with academic institutions, must undergo background, reference, and credential checks before employment. During the survey, it was discovered that both the facility and the corporate office assumed the other party was responsible for conducting Intern D's background check, resulting in the process not being completed. Despite this oversight, Intern D was observed in resident care areas obtaining paperwork for surveyors, even though the administrator stated that Intern D was being kept in the office. This failure to follow established screening procedures directly contravened the facility's abuse prevention policy.
Failure to Revise Care Plan After Removal of Side Rails
Penalty
Summary
The facility failed to revise the care plan for a resident after the removal of side rails from her bed. The resident, who had diagnoses including congestive heart failure, morbid obesity, and anxiety disorder, was cognitively intact and had previously expressed a desire to have side rails to promote independence. The care plan, last updated in June, still listed side rails as an intervention for mobility impairment, despite their removal. Audits by the speech-language pathologist indicated the care plan had been updated, but the intervention remained unchanged in the documentation. Observations on July 8 confirmed that the resident's bed no longer had side rails, and the resident reported that the rails were removed during a hospitalization and not returned, with no alternative assistive device provided as promised. The DON confirmed the side rails were removed per protocol after the resident's hospital discharge and stated that side rails would not improve the resident's bed mobility. The failure to update the care plan to reflect the removal of side rails constituted the deficiency.
Lack of Qualified Director and Full-Time Dietician in Food and Nutrition Services
Penalty
Summary
The facility failed to designate a director of food and nutrition services who met the minimum qualification requirements as outlined in their own policy. The current Dietary Manager (DM) is enrolled in a Nutrition & Food Service Professional Program but has not yet completed it, having received an extension to finish the program by a later date. The facility policy requires the director to have certification as a dietary manager, certification as a food service manager, an associate or higher degree in food service management or hospitality with relevant coursework, or at least two years of experience in the position along with completion or enrollment in a food safety management course. The DM does not currently meet these qualifications, as she is still in the process of completing her required program. Additionally, the facility does not have a full-time Registered Dietician (RD) on staff. The RD is only present in the facility one to two days per week, which does not fulfill the requirement for a full-time RD. This lack of appropriately qualified staff in the food and nutrition services department could potentially affect all 48 residents residing in the facility, as noted by the surveyor during interviews and record review.
Deficient Food Handling, Storage, and Sanitation Practices
Penalty
Summary
The facility failed to prepare, store, and distribute food in a sanitary manner, as evidenced by multiple observations and staff interviews. A dietary aide was seen removing clean drinking glasses and plastic mixing containers from the dishwasher, stacking them together while still wet, and placing them in storage, causing water to drip on the floor and counter. The dietary aide acknowledged that dishes should be dry before being stacked and stored, and the dietary manager confirmed that this practice did not meet facility expectations or established food safety standards. Additionally, the kitchen's handwashing sink was observed to have heavy lime and dirt buildup on the faucet handles, drain, and basin. The dietary aide was unable to recall when the sink was last deep cleaned, and the dietary manager confirmed that the cleanliness of the sink did not meet expectations. The cleaning schedule was found to be lacking a specific task for deep cleaning the handwashing sink, which was only added after the surveyor's observation. Further deficiencies were noted in the storage of resident food brought in from outside sources. Refrigerators and freezers contained multiple opened food items without labels indicating the contents, resident names, or dates. Some food items prepared by the facility and not consumed during mealtimes were also stored without proper labeling. The dietary manager acknowledged that these practices did not meet facility policy and expressed concern about the potential for expired foods to cause foodborne illness.
Environmental Deficiencies: Unsafe, Unsanitary, and Uncomfortable Facility Conditions
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for all 48 residents, as evidenced by multiple observations of frayed carpeting, stained flooring, and damaged walls throughout the building. Surveyors noted frayed carpet in several hallways and common areas, with specific mention of fraying around metal circles in the floor and along seams. Numerous dark and white spots were observed on the carpets in various hallways, with some spots being large in size. Staff, including housekeeping, RN, and DON, were unable to identify the cause of the spots, and the DON confirmed that the spots had been present since her hire date in 2022. The Maintenance Director indicated that the carpets had been shampooed only a few times in the past six months and suggested that improper cleaning or treatment may have contributed to the stains. Additionally, a bathroom floor was found to be completely stained, and staff acknowledged the poor condition of the flooring. Further deficiencies were observed in the condition of the walls, including unfinished sheetrock, puncture marks, black marks, missing paint, and cracks. The Maintenance Director attributed some of the wall damage to wheelchairs or carts and acknowledged being unable to address all maintenance needs due to limited staffing. The DON stated that these issues had been reported to corporate but was unable to provide documentation of any follow-up. No specific residents were identified as being directly affected at the time of the survey, but the environmental deficiencies were present in areas accessible to all residents, staff, and the public.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans that addressed all identified needs and preferences for two residents. For one resident, there was no activity care plan that included accommodations for vision and hearing deficits, despite the resident reporting difficulty hearing and seeing during activities such as bingo, and needing to sit close to the caller to participate effectively. The resident also stated that food preferences were not assessed or accommodated, and no alternatives were offered for foods she could not eat. Review of the care plan and interviews with staff revealed that vision and hearing accommodations, as well as specific food preferences, were not documented or implemented, and the process for assessing and updating these preferences was inconsistent or incomplete. For another resident with a history of spina bifida, pressure ulcers, osteomyelitis, and catheter-associated urinary tract infections, the care plan did not include a safe smoking plan, even though the resident was observed smoking outside without staff assistance and was unable to pick up a dropped lighter. Although a smoking safety assessment indicated the resident could smoke without supervision, the care plan lacked details on supervision requirements, safety measures, and storage of smoking materials. Staff interviews confirmed that the omission of a smoking care plan was an oversight.
Failure to Provide Ordered Wound Care and Services for Resident with Diabetic Ulcers
Penalty
Summary
A resident with multiple chronic conditions, including diabetes, peripheral vascular disease, and a history of wounds, did not receive necessary wound care and related services as ordered. The resident had active wound treatment orders that lapsed for several days, leaving a period with no documented wound care provided. Orders from a wound clinic, including those for nutritional supplements and the use of a protective boot, were not transcribed or implemented in a timely manner. Additionally, recommendations from a registered dietician for a zinc supplement to promote wound healing were not addressed or documented as ordered. Observations and interviews revealed that wound care was not consistently performed according to the prescribed schedule, and the resident reported that dressing changes were missed for up to two days. The Prevalon boot, ordered to be worn at all times, was not consistently applied, with documentation showing it was only in use during certain shifts and not daily as required. There was no evidence of resident refusal or documentation of risks and benefits related to the boot in the care plan. The treatment administration record (TAR) did not reflect all required treatments, and staff interviews indicated confusion or lack of clarity regarding the implementation and monitoring of wound care orders. The facility's failure to ensure timely transcription and implementation of physician and wound clinic orders, as well as to follow through on dietician recommendations, resulted in gaps in care for the resident. Documentation and monitoring were inconsistent, and there was a lack of communication and follow-up regarding new orders and recommendations. These actions and inactions led to the resident not receiving the necessary treatment and services to promote wound healing as required by facility policy and physician directives.
Failure to Maintain Infection Control During Catheter Care and Dressing Change
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two of four sampled residents. For one resident with a urinary catheter, repeated observations showed the catheter urine collection bag was positioned on the lowest part of the wheelchair crossbars, causing it to rest on and drag across the floor as the resident moved throughout the facility. The facility's catheter care policy did not address proper positioning of the catheter bag, and the infection preventionist confirmed that catheter bags should be kept off the floor to prevent contamination. In a separate incident, during a dressing change for another resident with multiple pressure injuries and receiving hospice care, clean gauze intended for use between the toes was observed touching the floor and lying under the nurse's foot. Additionally, the measuring tool used for wound assessment was also in contact with the floor. The nurse acknowledged that items which had touched the floor should not have been used during the dressing change, and the Director of Nursing confirmed this expectation.
Deficiency in Mechanical Lift Safety and Sling Size Determination
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, specifically concerning the use of mechanical lifts for resident transfers. On one occasion, staff did not verify the proper sling size or the safe functioning of the mechanical lift before transferring a resident, resulting in the lift tipping over and causing the sling bar to strike the resident in the face. This incident led to a bruise and laceration below the resident's left eye, requiring hospital transfer and tissue adhesive repair. Observations revealed that staff were not aware of how to determine the proper sling size for residents, and the care plans did not specify the type or size of sling to be used. The maintenance staff lacked the necessary knowledge to inspect and ensure the safety of the mechanical lifts. The Maintenance Director admitted to not receiving specific training on the equipment and was unable to determine if the lifts were operating safely. A mechanical lift used in the incident had a defect that allowed its base legs to move to a closed position without using the foot lever, a condition that had been reported but not addressed. This lack of proper maintenance and inspection posed a safety risk to all residents using mechanical lifts. Additionally, the facility did not have a clear system for determining and labeling sling sizes. Staff relied on visual comparison to choose slings, as there were no labels or reference charts available to guide them in selecting the appropriate size based on residents' weight and height. The Nursing Home Administrator was unaware of the manufacturer's guidelines for sling size determination and the available sizes in the facility. This lack of knowledge and resources contributed to the potential for unsafe transfers, affecting all residents who required mechanical lifts.
Inadequate Supervision During Hoyer Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance during a Hoyer lift transfer for a resident, leading to a serious accident. A Certified Nursing Assistant (CNA) transferred the resident using a Hoyer lift without the required assistance of another staff member, contrary to the facility's policy that mandates two people for all mechanical lift transfers. During the transfer, the resident slipped out of the sling and fell to the floor, resulting in a subarachnoid hemorrhage, subdural hematoma, and other injuries, necessitating hospitalization. The resident involved had a history of dementia and anxiety disorder and required total assistance with activities of daily living. The resident was identified as a fall risk, with a care plan that included the use of a Hoyer lift for transfers. On the day of the incident, the CNA did not request assistance from a nearby nurse and proceeded with the transfer alone, using an uncrossed sling, which was not specified in the care plan. This oversight led to the resident sliding out of the sling and sustaining severe head injuries. The incident was immediately investigated by the facility, revealing that the CNA was aware of the two-person policy but did not adhere to it. The facility had previously conducted education on Hoyer lift use, but the care plan lacked specific instructions on crossing the straps between the resident's legs. The failure to follow established procedures and ensure proper supervision during the transfer resulted in significant harm to the resident.
Removal Plan
- The facility completed resident care plan reviews for the residents who require mechanical lift transfers.
- The facility provided reeducation on mechanical lift use, requirement for 2 staff to be present during the entire transfer, and use walkie talkies to ask for assistance, and if unsure how to transfer a resident, staff is to seek clarification from a nurse.
- Licensed nursing staff educated on updating a resident care plan if the straps are to be crossed for the transfer.
- CNA C's employment with the facility was terminated.
Financial Mismanagement Leads to Service Disruptions
Penalty
Summary
The Bedrock corporation governing body failed to ensure adequate funds were available for the safe and efficient management of the facility, affecting all 51 residents. The governing body did not maintain current payment status with several service providers and vendors, leading to vendors refusing to provide services or issuing discontinuation notices until payment was received. This included the abrupt termination of the facility's pharmacy provider after a past due notice, and the potential disruption of services due to unpaid state bed taxes and civil money penalties. The facility's aging vendor report revealed significant outstanding balances with multiple vendors, some dating back over three years. The surveyor verified these balances with various service providers, confirming discrepancies between the amounts owed and those reported by the facility. For instance, the facility owed substantial amounts to a gas supplier, food supplier, and transportation services, with some services already halted due to non-payment. Additionally, the facility breached its contract with a garbage removal service, leading to legal action. The Nursing Home Administrator (NHA) was interviewed and stated that they only see invoices for services and supplies, which are then sent to corporate for payment. The NHA was not informed of past due amounts or when invoices were paid, and was unaware of the reasons behind the change in pharmacy service. Despite these financial issues, the NHA reported no disruptions in utilities, internet, or food services, although the facility's financial mismanagement posed a risk to the quality of care and life for residents.
Failure to Provide Timely Transportation for Resident
Penalty
Summary
The facility failed to provide necessary transportation services for a resident, identified as R2, who was sent to the hospital for an emergency evaluation due to chest pain and shortness of breath. R2, who has severe cognitive impairment and multiple medical conditions including atrial fibrillation and hepatocellular carcinoma, was discharged from the hospital on the same day but was unable to return to the facility until the following morning. This delay was due to confusion over transportation responsibilities between the facility and the managed care organization, resulting in R2 remaining at the hospital overnight. Interviews with facility staff and the managed care organization revealed a lack of clarity regarding who was responsible for arranging transportation for R2. The Assistant Director of Nursing and the Nursing Home Administrator both indicated that transportation is typically arranged by the managed care organization for residents under their care, but the facility also has a van service available during daytime hours. However, this service does not operate after hours, and alternative transportation options were not available. The facility's inability to secure transportation during off hours has been a recurring issue, particularly in rural areas where services are limited.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. The staffing ratios did not align with the facility's assessment of staffing needs, particularly during the night shift, where the licensed nurse-to-resident ratio was higher than planned. This discrepancy resulted in delayed responses to call lights and unmet resident needs, as observed by surveyors and reported by residents and staff. Residents expressed dissatisfaction with the timeliness of care, with some waiting extended periods for assistance, leading to discomfort and unmet personal care needs. Multiple residents reported waiting for assistance with daily activities, such as getting ready for the day or being helped to the toilet, for extended periods. One resident, for example, had their call light on for nearly 45 minutes before receiving help. Staff interviews revealed that they were overwhelmed and unable to complete their tasks due to the high acuity of residents and insufficient staffing levels. The facility's staffing plan did not account for the increased needs of residents requiring two-person assistance or those with high acuity conditions, leading to rushed and incomplete care. The facility's failure to address staffing concerns was further highlighted by resident council minutes and grievance reports, which consistently noted issues with call light response times and inadequate staffing. Despite staff and resident complaints, the administration had not effectively addressed these concerns, resulting in ongoing deficiencies in care. The lack of agency staff and the facility's rural location compounded the staffing challenges, leaving the facility unable to meet the care needs of its residents adequately.
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Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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