Alden Estates Of Countryside, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Jefferson, Wisconsin.
- Location
- 1130 Collins Road, Jefferson, Wisconsin 53549
- CMS Provider Number
- 525271
- Inspections on file
- 33
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Alden Estates Of Countryside, Inc during CMS and state inspections, most recent first.
An LPN failed to consistently perform hand hygiene before and after wearing gloves while conducting blood glucose checks for multiple residents, including those on enhanced precautions. The LPN was observed entering rooms, handling supplies, and cleaning equipment without following proper hand hygiene protocols, contrary to facility policy and infection prevention expectations.
A resident with a history of traumatic brain injury and chronic kidney disease was prescribed Keppra for 7 days as seizure prophylaxis, but due to the facility's failure to clarify and follow the physician's order, the medication was administered for an extended period. This led to the resident experiencing a significant decline, including lethargy, weight loss, and eventual hospital readmission for acute metabolic encephalopathy, with hospital records citing continued Keppra use as a contributing factor. The facility did not thoroughly investigate the medication error.
Surveyors found that the facility failed to comprehensively assess, care plan, and implement interventions for several residents at risk for or with pressure injuries. Multiple residents with complex medical conditions developed new or worsening wounds without timely or complete assessment, staging, or care plan updates. Staff sometimes performed wound care without proper documentation or licensure, and preventive measures such as pressure-relieving devices and positioning were inconsistently used. These failures resulted in the development of avoidable pressure injuries, including a stage 4 wound with osteomyelitis, and led to a finding of immediate jeopardy.
Staff did not consistently wear beard restraints while preparing and serving food, with observations of both the Dietary Director and a cook failing to properly cover facial hair as required by policy. This lapse in sanitary practice had the potential to affect all residents receiving meals.
The facility did not accurately submit required direct care staffing data to CMS, resulting in discrepancies in reported staffing levels and a low staffing rating. A newly licensed LPN was incorrectly reported as an aide, and a recent change in payroll vendors contributed to the reporting error. Despite maintaining minimum staffing levels according to schedules, the inaccurate classification of staff led to incomplete and incorrect PBJ data submission.
Surveyors observed multiple instances where residents were not treated with dignity, including a resident with an uncovered catheter drainage bag visible in public areas, a resident with dementia left unattended and without adaptive utensils during meals, and another resident dependent on staff for eating who was referred to as a "feeder" and left alone with food. Staff interviews confirmed these actions did not align with facility policies on dignity and respect.
Two residents were administered psychotropic medications without the required baseline AIMS assessments, as mandated by facility policy. One resident with Alzheimer's and dementia received an antipsychotic without any documented AIMS assessment, and another resident with multiple neurological and psychiatric diagnoses was given Memantine and Mirtazapine before an AIMS assessment was completed. This deficiency was identified through record review and staff interviews.
Two residents at high risk for falls did not receive adequate supervision or assistance devices as required by their care plans. One resident with Parkinson's and dementia experienced multiple unwitnessed falls, with facility investigations lacking key details such as call light response times and whether interventions were in place. Another resident with severe cognitive impairment and recent decline was transferred by a single staff member without a gait belt, despite a care plan requiring a mechanical lift with two staff, and the prompted toileting program was not consistently followed. Staff interviews revealed gaps in awareness and communication about residents' care needs.
A resident with a history of depression and other medical conditions expressed to a CNA that they did not want to live. Facility staff did not complete a suicidal evaluation, notify the physician or psychologist, or develop a care plan to address the resident's depression, despite policy requirements and subsequent assessments indicating moderate depressive symptoms. Interviews revealed staff were unclear on appropriate follow-up, and no interventions for mood concerns were documented.
A resident with multiple complex medical conditions did not receive required monthly drug regimen reviews by a licensed pharmacist for two months, as documented in the medical record. Facility leadership acknowledged the missing reviews and attributed one lapse to the resident's hospitalization, but no documentation was provided to account for the missed pharmacist reviews.
Two residents prescribed Eliquis for conditions such as atrial fibrillation and pulmonary embolism did not have documented monitoring for potential adverse effects like bleeding or bruising. Staff confirmed that monitoring should occur, but the facility lacked a policy for anticoagulant monitoring other than for Warfarin, and no evidence of monitoring was found in the medical records.
A resident with a physician order for a mechanical soft diet was served a regular diet meal instead of the required mechanically altered meal. The facility's policy outlines the need for food modification for those with chewing difficulties, but during meal service, only one of two residents with this diet order received the correct meal. The error was identified and reported, with no explanation provided for the dietary mistake.
A resident with severe cognitive impairment and recent right-hand weakness did not consistently receive adaptive eating utensils and cups as recommended by occupational therapy. Despite therapy's instructions and documentation by CNAs, the adaptive equipment was not always provided during meals due to unclear responsibilities and lack of care plan updates, resulting in the resident struggling to eat independently and safely.
Two residents with stage 3 pressure injuries and chronic wounds were not consistently placed on Enhanced Barrier Precautions (EBP) as required by facility policy and CDC guidance. Staff failed to follow EBP protocols during wound care, did not maintain proper documentation or signage, and demonstrated confusion about when to initiate or discontinue EBP. These lapses resulted in inadequate infection prevention and control for residents with ongoing wound care needs.
Three cognitively intact residents with significant medical histories were not offered or documented as having refused the pneumococcal vaccine upon admission, despite being eligible and lacking immunization records. The ADON reported not being aware of the requirement to address vaccinations at admission, and consents were only obtained after surveyor inquiry.
Surveyors found that three residents with complex medical conditions did not have documentation in their medical records indicating whether they were offered, received, or declined the COVID-19 vaccine. The ADON reported not being aware of the requirement to address vaccination status at admission, and consents were only obtained after the issue was raised by surveyors. No evidence was provided to show that these residents were offered or refused the vaccine at the time of admission.
A resident with severe dementia and escalating aggressive behaviors was not provided with increased supervision or individualized interventions, despite repeated incidents of agitation, wandering, and physical aggression toward staff and other residents. This lack of adequate monitoring allowed the resident to enter another resident's room and physically assault them after a fall, demonstrating the facility's failure to protect residents from abuse.
A resident with multiple comorbidities and on hospice care was transferred by a CNA without the required EZ-stand, resulting in knee pain and swelling. Despite ongoing complaints and visible injury, thorough assessments and vital sign monitoring were not completed, and communication with the physician, hospice, and responsible party was insufficient. The resident's condition declined, leading to death from a femur fracture, and the facility's failure to follow care plans and ensure timely assessment and notification led to an immediate jeopardy finding.
A resident with Parkinson's Disease and on hospice care was transferred by a CNA using a pivot transfer instead of the care-planned EZ stand, resulting in severe knee pain, swelling, and bruising. The incident was not immediately reported as a fall, and the resident's condition declined over several days, culminating in death. An autopsy confirmed a left distal femur fracture caused by the improper transfer, and the facility failed to provide adequate supervision and follow the resident's care plan.
The facility did not maintain adequate nursing staff as outlined in its Facility Assessment, resulting in residents experiencing long wait times for assistance, especially during busy periods and weekends. Two residents, one requiring a Hoyer lift and another dependent on oxygen, reported significant delays in care. Staff interviews confirmed frequent staffing shortages, particularly on weekends, and a review of schedules showed the facility was consistently below required nurse and CNA levels. Both residents and staff expressed concerns about the impact of these staffing shortfalls.
A resident with Parkinson's Disease, requiring an EZ stand and one-person assist for transfers, suffered a left distal femur fracture after being transferred incorrectly by staff. Despite the resident's complaints of severe pain and visible injury, the incident was not reported to the Nursing Home Administrator or State Agency as required by facility policy. The facility failed to document the event in its grievance log or submit a Facility Reported Incident, and leadership relied on an inappropriate reporting algorithm, resulting in a lack of timely investigation and reporting.
A resident who required an EZ stand for transfers was instead moved by a pivot transfer, resulting in pain, swelling, and bruising to the left knee, followed by a significant decline and death. Despite staff awareness of the incident and the resident's subsequent injuries, the event was not reported to the administrator or State Agency as required by facility policy. The medical examiner later determined the cause of death was a femur fracture consistent with a fall or drop, but the facility did not submit a Facility Reported Incident or notify authorities in the required timeframe.
Two residents were not seen by a physician or physician extender at the required intervals, with one resident lacking alternating visits between physician and nurse practitioner, and another experiencing extended gaps between physician assessments, contrary to facility policy and regulatory requirements.
Two residents experienced falls due to inadequate supervision and care planning. One resident, with multiple medical conditions, fell while receiving care, resulting in a laceration and femur fracture. The facility did not conduct a thorough investigation or implement specific interventions. Another resident, severely cognitively impaired, had multiple falls with one causing injury. The facility failed to complete thorough investigations or establish specific interventions to prevent further falls.
The facility failed to provide sufficient nursing staff to meet residents' needs, leading to long call light wait times and unmet care requirements. Residents and staff reported concerns about staffing shortages, particularly on weekends and nights. Staffing records showed consistent shortfalls in CNA numbers compared to assessed needs, with the facility failing to meet requirements on multiple days.
The facility failed to consistently provide water to residents, as required by their policy. Several residents reported only receiving water upon request, and some did not receive it at all. Observations confirmed the absence of water glasses in some rooms, and staff interviews revealed inconsistencies in water distribution practices. The Director of Nursing and other administrative staff were informed, but no explanation was provided for the inconsistency.
A resident with moderate cognitive impairment reported being yelled at and handled roughly by a CNA. The facility's Assistant Administrator was informed but did not document or formally investigate the allegations, only providing a verbal warning to the CNA. The lack of a formal investigation and documentation constitutes a deficiency in compliance with the facility's abuse policy.
A resident with multiple medical conditions was prescribed Lorazepam 0.5 mg every four hours PRN for anxiety without an end date. Upon review, the surveyor found the order lacked a stop date, which was later added by the Regional Nurse Consultant. The facility's policy did not address stop dates for PRN psychotropic medications, and staff were unclear about responsibility for ensuring these dates.
A resident with chronic pain did not receive their prescribed Oxycodone 5mg on multiple occasions due to issues with reordering and obtaining prescriptions. Despite the facility's policy to reorder medications in advance, the medication was unavailable on several dates, leading to significant pain for the resident. Staff interviews revealed challenges in obtaining timely prescriptions from the nurse practitioner, contributing to the deficiency.
A resident with a complex medical history, including dementia and a-fib, experienced significant changes in condition following unwitnessed falls. Despite symptoms indicative of a head injury, such as altered mentation, pain, and vomiting, the facility did not promptly consult the resident's physician, Medical Director, or Hospice provider. The facility's policy on Change in Condition, which outlines procedures for notifying physicians of any changes, was not followed. The lack of communication and coordination between facility staff, hospice provider, and the resident's physician led to a delay in appropriate medical intervention, contributing to the resident's deteriorating health status.
A nursing home faced deficiencies in preventing accidents and falls, particularly for a resident with dementia and anxiety, assessed as high risk for falls. The resident experienced two unwitnessed falls resulting in significant injuries, including head trauma and cognitive impairment. The facility did not conduct post-fall investigations or revise the care plan to address the risks. Incidents included a fall in the bathroom and another while reaching for an out-of-reach call light. There was inadequate documentation and notification to the medical team about the resident's changing condition, such as weakness and altered speech. Despite existing policies on fall prevention and post-fall protocols, these measures were not effectively implemented.
The report identifies deficiencies in the communication and coordination processes between hospice, the facility, the physician, and the power of attorney for a resident with complex medical conditions. The resident experienced significant changes in condition, including unwitnessed falls, altered mentation, slurred speech, and weakness. Critical information about these changes was not consistently relayed to the physician, power of attorney, or hospice, leading to lapses in comprehensive care planning and decision-making. Delays in notifying appropriate parties about significant changes impacted the continuity of care and the resident's evolving care needs.
A resident at high risk for pressure ulcers developed a stage 4 pressure ulcer on the back of the left lower leg due to the facility's failure to monitor the skin under a knee immobilizer. Despite hospital discharge instructions and physician orders, regular skin assessments were not conducted, and the ulcer was discovered during a random check by the Director of Nursing.
The facility failed to ensure proper N95 mask fit testing for staff exposed to COVID-19 and did not maintain a sanitary environment for a resident with a Foley catheter, leading to increased infection risk.
The facility failed to provide required written notice information related to resident transfers to the hospital, affecting seven residents. The notices lacked details on appeal rights and contact information for the Ombudsman and other relevant agencies. The facility acknowledged the issue but had not yet updated their forms and policies to comply with the requirements.
A resident with a history of multiple health issues experienced a left distal femur fracture, which was not reported to the State Survey Agency within the required 2-hour timeframe. The facility also failed to submit the investigation results within 5 working days. The Director of Nursing could not provide evidence that the injury was pathological and did not report the injury, believing it was unnecessary.
The facility failed to ensure individualized comprehensive care plans for two residents, one with an indwelling catheter and another on anticoagulant medication. Interviews with staff confirmed these oversights were due to missed updates and transitions in staff responsibilities.
A facility failed to ensure a resident with an indwelling catheter received necessary urology consult services. Despite hospital discharge instructions and nurse practitioner's notes indicating the need for follow-up, the facility did not arrange a urology consult after the initial referral was canceled due to a subsequent hospital stay. The resident was unaware of the reason for the catheter, and the facility did not adhere to its policy for catheter removal assessment.
A resident was not properly assessed for bed rail use, and the facility lacked evidence that risks and benefits were discussed with the resident or their representative. Despite an assessment indicating no need for side rails, the resident's bed had fixed grab bars. Staff interviews revealed inconsistencies in the communication and documentation of side rail assessments.
The facility failed to ensure sufficient nursing staff to meet the needs of residents, leading to consistent low weekend staffing and unmet staffing requirements. Residents voiced concerns about insufficient care, and staff confirmed ongoing low staffing issues. The facility's algorithm for determining CNA needs was not met, and the acuity of residents was not considered in staffing calculations.
The facility failed to ensure proper use and documentation of psychotropic medications for three residents. One resident did not receive a recommended gradual dose reduction for an antidepressant, another was prescribed PRN Lorazepam without a documented rationale for extending its use beyond 14 days, and a third was given Primidone for essential tremors but had an incorrect diagnosis of seizures listed in their records.
The facility failed to display required information, including contact details for pertinent State agencies and advocacy groups, in the main entrance, lobby area, and all six units. The missing postings included essential information for residents to file complaints and report violations.
Failure to Perform Hand Hygiene During Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure that staff consistently performed hand hygiene before and after wearing gloves during blood glucose checks for five residents. Observations revealed that an LPN performed hand hygiene at the medication cart but did not consistently perform hand hygiene before donning gloves or after removing them when conducting blood glucose monitoring. The LPN was seen entering resident rooms, including those under enhanced precautions, donning gloves and gowns without prior hand hygiene, and performing fingerstick glucose checks. In several instances, the LPN removed gloves and gowns outside the resident rooms and failed to perform hand hygiene before proceeding to the next task or resident. The LPN was also observed handling the glucometer, medication cart, computer, and other supplies without performing hand hygiene between glove changes or after glove removal. Supplies such as lancets and testing strips were retrieved and handled without appropriate hand hygiene, and the LPN was seen touching personal items, such as cart keys and pockets, in between resident care activities. In some cases, the LPN cleaned the glucometer while wearing gloves, removed the gloves, and then failed to perform hand hygiene before touching other surfaces or equipment. Interviews with the LPN confirmed the failure to perform hand hygiene as required. The facility's infection prevention policy specifies that hand hygiene must be performed before donning gloves and after removing them, especially when performing procedures involving potential exposure to blood or body fluids. The Infection Preventionist stated that it was her expectation for staff to follow these protocols, but the observed practices did not align with facility policy.
Failure to Clarify and Follow Physician Order for Keppra Results in Harm
Penalty
Summary
A significant medication error occurred when a resident with a history of traumatic brain injury, chronic kidney disease stage 3, heart failure, and dysphagia was prescribed Levetiracetam (Keppra) for 7 days as seizure prophylaxis following hospital discharge. The facility failed to clarify, accurately transcribe, and follow the physician's order, resulting in the resident receiving Keppra for an extended period beyond the intended 7 days. The hospital discharge summary and related documentation repeatedly indicated that Keppra was to be administered for only 7 days, but the facility continued administration for approximately two weeks longer than prescribed. During this period, the resident exhibited a decline in condition, including increased lethargy, decreased appetite, weight loss, and reduced participation in therapy. Family members raised concerns about the resident's lethargy and possible side effects of Keppra, but the medication was only tapered and not discontinued until much later. The resident's condition continued to deteriorate, leading to a hospital readmission where acute metabolic encephalopathy, aspiration pneumonia, and acute kidney injury were diagnosed. Hospital records specifically noted that the continued use of Keppra was a contributing factor to the resident's encephalopathy, and the medication was discontinued during the hospital stay. The facility's process for entering and verifying new medication orders involved multiple staff members, but there was a failure to clarify the duration of the Keppra order despite clear indications in the hospital documentation. Interviews with facility staff revealed a lack of thorough review and understanding of the discharge instructions, and no documentation of a thorough investigation into the medication error was provided. The facility's own policy defined medication errors as preventable events that may cause harm, yet the error was not recognized or reported by staff until it resulted in actual harm to the resident.
Failure to Assess, Care Plan, and Prevent Pressure Injuries Leads to Immediate Jeopardy
Penalty
Summary
Surveyors identified that the facility failed to ensure comprehensive assessment, care planning, and implementation of interventions to prevent and treat pressure injuries for multiple residents. Several residents with significant comorbidities, such as diabetes, heart failure, immobility, and cognitive impairment, were at risk for pressure injuries or developed new wounds while in the facility. In multiple cases, when new wounds or pressure injuries were discovered, there was no evidence of timely or comprehensive assessment, staging, or documentation. For example, one resident developed a pressure injury to the left buttock and a blood blister to the right great toe, but the medical record lacked a comprehensive assessment, and the care plan was not updated to reflect these new wounds or interventions to promote healing. Additionally, treatments were sometimes performed by unlicensed staff, and documentation of wound care was inconsistent or incomplete. Another resident with a history of hemiplegia, diabetes, and impaired mobility developed multiple pressure injuries, including a deep tissue injury (DTI) to the left medial foot and additional DTIs to the left lateral foot and fifth toe. The care plan was not updated to address the resident's specific positioning challenges, such as outward rotation of the left leg, and interventions like heel offloading were not consistently implemented or documented. Observations revealed that pressure-relieving devices were not always in use, and staff were sometimes unaware of new wounds. Comprehensive assessments and care plan updates were delayed or missing, and the facility did not ensure that all wounds were properly identified, staged, and treated according to standards of practice. In another case, a resident with severe cognitive impairment and total dependence for mobility developed a large intact blister on the left heel, later identified as a DTI. There was a delay of several days before a comprehensive assessment was completed, and wound measurements did not include depth until much later. The care plan was not promptly revised to reflect the new pressure injury or to implement additional preventive measures. Across multiple cases, surveyors found that the facility did not consistently perform or document comprehensive skin assessments, update care plans, or ensure that interventions were in place and followed, resulting in the development and worsening of pressure injuries. These failures led to a finding of immediate jeopardy, particularly in the case of a resident who developed a facility-acquired, avoidable stage 4 pressure injury with osteomyelitis.
Failure to Ensure Proper Use of Beard Restraints During Food Preparation
Penalty
Summary
The facility failed to ensure that food was prepared and served in a sanitary manner, as required by both facility policy and regulatory standards. Surveyors observed multiple instances where staff did not wear beard restraints properly or at all while preparing food in the kitchen. Specifically, the Dietary Director was seen preparing food with a beard net that did not cover the mustache, and a cook was observed entering the kitchen and preparing food on two separate occasions without donning a beard net. These observations were made during food preparation times and involved staff with facial hair that was not properly restrained, contrary to the facility's stated policy. Interviews with staff confirmed that there was an expectation for facial hair coverings, but the practice was not consistently followed. The facility's policy on hair covering was reviewed, and there was some confusion regarding the requirements, as an updated policy was presented during the survey. The policy required mustache or beard restraints for facial hair exceeding half an inch in length, but federal regulations require that no facial hair be exposed. The deficiency had the potential to affect all 111 residents dining in the facility, as it created a risk of physical contamination of food during preparation and service.
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The facility failed to ensure the complete and accurate electronic submission of direct care staffing information to CMS, as required by federal regulations. During the review of Payroll Based Journal (PBJ) data for the second quarter, surveyors found discrepancies in the reported staffing levels, particularly noting excessively low weekend staffing and a one-star staffing rating. Upon review of the facility's weekend schedules and minimum staffing requirements, no discrepancies were found between scheduled and required staff. However, it was discovered that a Licensed Practical Nurse who had recently graduated and obtained licensure was still being reported as an aide in the PBJ submission, which contributed to the inaccurate data. Additionally, the facility had recently changed payroll vendors, and the reporting error was not corrected as intended for the first quarter. Interviews with the scheduler and the Nursing Home Administrator (NHA) revealed confusion regarding the reporting process and the source of the staffing data errors. The NHA acknowledged a reporting error and indicated that all hours, including agency staff, were supposed to be sent to corporate for submission. The scheduler described how staffing was managed during call-ins and confirmed that minimum staffing levels were maintained according to the facility assessment. Despite these efforts, the inaccurate reporting of staff roles led to the submission of incorrect staffing data to CMS, affecting the facility's reported staffing levels and ratings.
Failure to Maintain Resident Dignity and Respect During Care and Meals
Penalty
Summary
Multiple deficiencies related to resident dignity and respect were identified during surveyor observations and interviews. One resident with an indwelling urinary catheter was repeatedly observed without a privacy cover on the catheter drainage bag, both in her room and in common areas, making the bag visible to others. Despite care plan interventions specifying the use of a privacy cover and staff acknowledging the requirement for such covers, the resident's catheter bag remained uncovered on several occasions. The resident herself confirmed that the drainage bag was not always covered when she moved throughout the facility. Additional deficiencies were observed in the dining area involving two other residents. One resident with severe cognitive impairment and a diagnosis of dementia was seen sleeping with her head in her lap at the dining table, with food scattered around her bowl and no staff present to assist. Later, a CNA was observed feeding this resident while standing over her, contrary to facility training that requires staff to sit at eye level with residents during feeding to maintain dignity. The resident was also noted to lack adaptive utensils recommended by occupational therapy. Another resident, who was completely dependent on staff for eating due to severe cognitive and physical impairments, was referred to as a "feeder" by staff calling across the dining room. This resident was also left alone at a table with food placed in front of her, despite being unable to feed herself. Staff interviews confirmed that this was not appropriate and did not align with facility policies or training on maintaining resident dignity and respect.
Failure to Complete Required AIMS Assessments Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that two residents were free from chemical restraints by not performing required Abnormal Involuntary Movement Scale (AIMS) assessments prior to administering psychotropic medications. According to the facility's policy, a baseline AIMS assessment should be completed before starting antipsychotic medications, with reassessments every six months. For one resident with Alzheimer's disease and dementia, the surveyor found no evidence of an AIMS assessment in the electronic medical record despite the resident receiving Quetiapine Fumarate, an antipsychotic medication. The facility was unable to provide the requested AIMS assessment for this resident during the survey. Another resident, who had multiple diagnoses including Alzheimer's disease, dementia, and Parkinson's disease, was prescribed Memantine and Mirtazapine, both psychotropic medications. The surveyor noted that while an AIMS assessment was eventually provided, it was not completed prior to the initiation of these medications. The lack of timely AIMS assessments for both residents was confirmed through record review and interviews with facility staff, indicating non-compliance with the facility's own policy regarding the monitoring of residents on psychotropic medications.
Failure to Prevent Accidents and Ensure Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls received adequate supervision and assistance devices to prevent accidents. One resident with Parkinson's Disease, Lewy body Dementia, and congestive heart failure experienced multiple unwitnessed falls. The facility did not thoroughly investigate each fall to determine the root cause or confirm that all care plan interventions were in place and effective at the time of the incidents. Documentation revealed that the resident often attempted self-transfers despite being care planned for staff assistance and the use of a Hoyer lift. Investigations into the falls lacked critical information, such as call light response times, whether the bed was in the lowest position, and if other interventions were implemented. In several instances, the resident activated the call light as instructed, but still experienced a fall before staff arrived, and the effectiveness of this intervention was not evaluated. Another resident with severe cognitive impairment, a history of falls, and recent physical decline was not consistently provided with the required level of assistance for transfers and toileting. The care plan specified the use of a mechanical lift (Hoyer) with two staff for all transfers and a prompted toileting program to reduce self-transfer attempts. However, staff interviews and observations revealed that the resident was transferred by a single staff member without a gait belt, and the prompted toileting program was not consistently followed. Staff were not always aware of the resident's current transfer and toileting requirements, and documentation indicated that the resident continued to self-transfer, increasing the risk of falls. The facility's failure to ensure that care plan interventions were implemented and effective, to thoroughly investigate falls, and to provide adequate supervision and assistance devices for residents at high risk for falls resulted in repeated incidents. Staff interviews indicated a lack of awareness and communication regarding residents' care plans and interventions, and investigations did not consistently review whether all safety measures were in place at the time of each fall.
Failure to Provide Necessary Behavioral Health Services Following Resident's Expression of Not Wanting to Live
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received necessary behavioral health care and services to maintain the highest practicable mental and psychosocial well-being, as required by the comprehensive assessment and care plan. The resident, who had a history of depression, adjustment disorder, and other significant medical conditions, expressed to a CNA that they did not want to live. Despite this statement, there was no documentation that a suicidal evaluation was completed, the physician or psychologist was notified, or a care plan was developed to address the resident's depression or mood concerns. The facility's policy required staff to assess and respond to expressions of suicidal ideation or passive death wishes, including offering psychosocial support and developing a care plan for passive statements. However, after the resident's statement, the RN instructed the CNA to notify social services but did not follow up with the resident or ensure an assessment was completed. There was also no evidence that the psychologist was informed of the resident's statement, and no care plan was initiated to address the resident's depression, even after subsequent assessments indicated moderate depressive symptoms and a care area assessment recommended care planning for mood. Interviews with facility staff revealed a lack of clarity and follow-through regarding the appropriate response to the resident's statement. The RN could not recall which CNA reported the statement and did not know what interventions should have been implemented. The Director of Social Services stated the resident was not suicidal and did not complete an assessment at the time. The care plan did not address the resident's depression or its manifestations, and interventions for mood concerns were not documented, despite multiple triggers and recommendations for care planning.
Failure to Ensure Consistent Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review, including a review of the medical chart, for one of five residents reviewed. According to the facility's policy, the consultant pharmacist is required to review each resident's medication regimen monthly and provide a report to the director of nursing, with nursing staff responsible for following up with the prescribing physician as needed. For the resident in question, who had multiple complex diagnoses including pulmonary embolism, paraplegia, Parkinson's disease, Alzheimer's disease, dementia, mood disturbance, and anxiety, the electronic medical record showed that monthly medication reviews were not documented for two specific months. The surveyor found that the resident's medical record lacked evidence of pharmacist reviews for January and April, despite documentation of reviews in other months. When questioned, facility leadership acknowledged the missing reviews and explained that the resident's hospitalization in April may have contributed to the oversight, as the resident did not trigger for pharmacist review upon return. No documentation was provided to account for the missing reviews, confirming that the required monthly pharmacist review was not consistently performed for this resident.
Failure to Monitor Anticoagulant Therapy for Two Residents
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary medications by not adequately monitoring the use of anticoagulant medications, specifically Eliquis. One resident with a history of atrial fibrillation and hypertension, who was rarely to never understood, was prescribed Eliquis 5 mg twice daily. Review of the resident's medical records, including physician orders, MAR, and TAR, revealed no documented monitoring for potential adverse effects of the anticoagulant, such as bleeding, bruising, or fatigue, during the assessment period. Another resident, cognitively intact and diagnosed with pulmonary embolism, paraplegia, Parkinson's disease, Alzheimer's disease, dementia, mood disturbance, and anxiety, was also prescribed Eliquis 5 mg twice daily. Similarly, there was no documentation in the MAR or TAR of monitoring for signs and symptoms of adverse effects from the medication. Staff interviews confirmed that monitoring for side effects should occur and be documented, but the facility lacked a policy for monitoring anticoagulants like Eliquis or Xarelto, having only a policy for Warfarin. No further information or documentation was provided by the facility regarding monitoring practices.
Resident Served Incorrect Diet Despite Mechanical Soft Order
Penalty
Summary
A deficiency occurred when a resident with a physician order for a mechanical soft diet was served a regular diet meal instead of the prescribed mechanically altered meal. The facility's policy specifies that a mechanical soft diet is intended for individuals who have difficulty chewing, requiring certain foods to be modified for easier consumption. During a lunch observation, an aide prepared and served a regular diet plate to the resident who required a mechanical soft diet, while another mechanical soft meal was set aside and not served to the intended resident. The surveyor confirmed through interview and record review that two residents on the unit were prescribed mechanical soft diets, but only one received the correct meal. The error was identified when the aide removed the incorrectly served regular diet plate from the resident's table. The incident was discussed with the dietary director and reported to the nursing home administrator and director of nursing. No explanation was provided for why the wrong diet was served to the resident.
Failure to Provide Adaptive Eating Equipment as Recommended by Therapy
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and recent right-hand weakness did not consistently receive adaptive eating equipment as recommended by occupational therapy. The resident had a history of dementia and physical limitations, including a right-hand wrist drop, which led occupational therapy to recommend and implement the use of built-up handled utensils and two-handled cups to support the resident's independence during meals. Despite these recommendations, observations by the surveyor revealed that the resident did not have access to the required adaptive utensils and cups during two out of three observed meals. At times, the resident was left without staff assistance, resulting in spilled food and difficulty eating. Interviews with facility staff indicated confusion and lack of clarity regarding responsibility for ensuring the adaptive equipment was provided and documented in the care plan. The occupational therapist reported informing both unit and kitchen staff of the resident's needs and providing education sheets to the restorative nurse, who was expected to update the care plan. However, the restorative nurse did not place the necessary orders, and the dietary supervisor had not received the order through the nutrition management system, so the care plan was not updated to reflect the adaptive equipment requirement. Staff interviews also revealed uncertainty about where information regarding adaptive equipment could be found, and some staff were unaware of the resident's current needs. Documentation showed that certified nursing assistants were recording the use of adaptive utensils in their daily charting, but this was not consistently reflected in the resident's care plan or meal setup. The lack of coordination among therapy, nursing, restorative, and dietary departments led to the resident not receiving the prescribed adaptive equipment during meals, as observed by the surveyor. This failure to provide necessary adaptive eating devices as recommended by therapy and outlined in facility policy resulted in the identified deficiency.
Failure to Implement Enhanced Barrier Precautions for Residents with Chronic Wounds
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with chronic wounds and stage 3 pressure injuries. For two of six residents observed, there were lapses in following facility policy and CDC guidance for EBP. One resident was readmitted with a hospital-acquired stage 3 pressure injury and was placed on EBP; however, there was no visible indication of EBP in place during surveyor observations, and the care plan documented discontinuation of EBP before the wound had fully healed. During wound care, the nurse did not follow EBP protocols, and staff interviews revealed uncertainty about the resident's EBP status and the criteria for discontinuing precautions. Another resident with a history of chronic wounds and a stage 3 pressure injury was not placed on EBP until after surveyor observation of drainage from leg wounds. The care plan lacked documentation of EBP implementation following the resident's hospital readmission with a stage 3 pressure injury. Staff interviews indicated confusion about when EBP should be initiated and who is responsible for making that decision. There was also a delay in placing the resident on EBP after the onset of wound drainage, and staff were unclear about the chronicity and management of the wounds. Throughout the investigation, surveyors noted inconsistent application of EBP, lack of proper signage, and inadequate communication among staff regarding infection control measures. Staff members, including the DON and ADON, provided conflicting information about the criteria for EBP and the status of residents requiring precautions. Observations included therapy and nursing staff providing care without appropriate personal protective equipment, despite care plans indicating EBP was still in effect. These actions and inactions resulted in the facility not maintaining a safe and sanitary environment to prevent the transmission of communicable diseases and infections.
Failure to Offer and Document Pneumococcal Vaccinations for Eligible Residents
Penalty
Summary
The facility failed to ensure that pneumococcal immunizations were offered or refused as required for eligible residents. This deficiency was identified through interviews and record reviews, which revealed that three out of five residents whose immunization records were reviewed did not have documentation of being offered the pneumococcal vaccine upon admission. In each case, the lack of documentation persisted until after the surveyor requested evidence, at which point verbal consents were obtained. Specifically, one resident with a history of pulmonary embolism, lobar pneumonia, acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus, and chronic systolic heart failure was admitted without any record of being offered the pneumococcal vaccine. The Wisconsin Immunization Registry also did not show any record of administration, and the resident was eligible for the vaccine. Two other residents, both cognitively intact and with significant medical histories including enterocolitis, diabetes, COPD, heart failure, cellulitis, and sepsis, similarly lacked documentation of being offered or refusing the vaccine upon admission, despite being eligible. During interviews, the Assistant Director of Nursing (ADON) indicated a misunderstanding regarding the requirement to offer vaccinations to short-term residents and was unaware that this should be addressed at admission. The ADON stated that consents were only obtained after the surveyor's inquiry and that the facility had recently held a vaccination clinic but had not ensured all eligible residents were offered the vaccine at admission. No further evidence was provided to show that the vaccine was offered or refused by the residents at the appropriate time.
Failure to Document COVID-19 Vaccination Status for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure proper documentation of COVID-19 immunization status for three out of five residents reviewed. Specifically, the medical records for these residents did not contain any evidence that they were offered, received, or declined the COVID-19 vaccine. This lack of documentation was found despite the facility's policy requiring that each resident's medical record include information about vaccine education, administration, or refusal. The residents involved had significant medical histories, including conditions such as pulmonary embolism, pneumonia, respiratory failure, diabetes, heart failure, enterocolitis, COPD, cellulitis, and sepsis. All three residents were assessed as cognitively intact according to their Brief Interview for Mental Status (BIMS) scores. Upon review of their electronic medical records, surveyors were unable to locate any documentation regarding COVID-19 vaccination offers or decisions at the time of admission. During interviews, the Assistant Director of Nursing (ADON) indicated a misunderstanding of the requirement, believing that vaccination status did not need to be addressed for short-term residents and was unaware of the need to ask about vaccination at admission. The ADON stated that consents were only obtained after the surveyor's inquiry and that the facility was in the process of arranging another vaccination clinic. No evidence was provided to show that the residents were offered or refused the vaccine at admission prior to the surveyor's request.
Failure to Protect Residents from Abuse Due to Inadequate Supervision of Aggressive Resident
Penalty
Summary
The facility failed to protect residents from abuse when a resident with severe dementia and a history of agitation, wandering, and physical aggression was not provided with increased supervision despite escalating behaviors. This resident exhibited daily physical behaviors toward others, including hitting, kicking, and attempting to bite both staff and other residents. On the day of the incident, the resident was observed wandering into multiple resident rooms, displaying aggression, and was repeatedly redirected by staff without success. Staff interviews and progress notes documented that the resident was agitated and combative throughout the day, with multiple unsuccessful attempts to manage the behaviors. Despite the resident's known behavioral risks and a care plan that referenced interventions for redirection and monitoring, the interventions were not individualized and did not address the specific aggressive behaviors toward others. The care plan also did not include increased supervision or one-on-one monitoring, even as the resident's behaviors escalated. Staff statements confirmed that no staff member was specifically assigned to provide one-on-one supervision, and staff were unable to continuously monitor the resident due to other duties. The resident was able to access other units and resident rooms, leading to an incident where the resident entered another resident's room, resulting in a physical altercation. During the altercation, the resident entered another resident's room, and after the other resident fell, began hitting and kicking the resident on the floor. Staff responded and separated the residents, but the lack of increased supervision allowed the incident to occur. The facility's failure to implement individualized interventions and provide adequate supervision for a resident with escalating aggressive behaviors resulted in a failure to protect residents from abuse, as required by facility policy and regulatory standards.
Failure to Provide Person-Centered Care and Timely Assessment After Transfer Injury
Penalty
Summary
A deficiency occurred when a resident did not receive care and services in accordance with a comprehensive assessment, person-centered care plan, and the resident's choices. The resident, who had multiple diagnoses including Parkinson's Disease, congestive heart failure, and was on hospice care, was assessed to require an EZ-stand and assist of one for transfers. However, a Certified Nursing Assistant (CNA) transferred the resident using a pivot transfer without the EZ-stand, contrary to the care plan. Following this transfer, the resident began experiencing left knee pain, swelling, and hematoma, which was reported to nursing staff. Despite the resident's complaints of pain and visible injury, a thorough assessment including vital signs was not completed after the initial telehealth visit. Orders for pain management and comfort measures were implemented, but there was no imaging performed to rule out a fracture, and documentation shows inconsistent application of topical treatments. The resident's pain persisted, and she began refusing care, meals, and assistance. There was a lack of ongoing, comprehensive assessment and insufficient communication with the resident's physician, hospice, and responsible party regarding the change in condition and the potential need to alter the plan of care. The resident's condition continued to decline, culminating in a further change of condition that required oxygen therapy due to respiratory distress. The responsible party was not promptly notified of the incident or the resident's deteriorating status. The resident ultimately passed away, and an autopsy revealed the primary cause of death was a fracture of the distal left femur. The facility's failure to complete ongoing assessments and communicate findings to appropriate parties resulted in a finding of immediate jeopardy.
Failure to Follow Care Plan for Safe Transfer Results in Resident Injury and Death
Penalty
Summary
A deficiency occurred when a resident, who had a history of Parkinson's Disease, atherosclerotic heart disease, and was on hospice care, was transferred by a CNA using a pivot transfer with assist of one, instead of the care-planned method of using an EZ stand with assist of one. The resident's care plan and assessments clearly documented the need for the EZ stand for all transfers due to substantial/maximum assistance requirements. Despite this, the CNA deviated from the care plan and performed a manual pivot transfer. Following this transfer, the resident complained of severe left knee pain, with swelling and bruising observed. The resident reported to multiple staff members that the EZ stand was not used and that she was dropped during the transfer, with her knee hitting the ground. Facility documentation and staff statements revealed inconsistencies and a lack of clear communication regarding the incident. Initial nursing notes did not document a fall or injury, and the incident was not immediately reported as a fall to hospice or the responsible party. The resident's condition deteriorated over the following days, with increased pain, swelling, and cognitive decline. Family members were not promptly informed of the incident or the resident's change in condition. The facility's investigation was delayed, and there was confusion among staff regarding the events that led to the injury. The responsible party only learned of the incident after observing the resident's decline and inquiring with staff. An autopsy determined that the resident suffered a fracture of the left distal femur related to the transfer, which was identified as the cause of death. The medical examiner concluded that the injury was consistent with a fall or being dropped, rather than a soft tissue injury or minor trauma. The facility failed to ensure adequate supervision and adherence to the resident's care plan, resulting in an accident hazard and a lack of appropriate intervention to prevent the injury and subsequent death.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff each day to meet the needs of all residents, as required by its own Facility Assessment. Interviews with residents revealed that they experienced significant delays in response to call lights, with some reporting wait times of up to an hour or more, particularly during busy periods such as mealtimes or when staff levels were low. One resident, who requires a Hoyer lift and assistance from two staff members for transfers, reported being the last to receive morning care and experiencing longer wait times when staffing was inadequate. Another resident, who is dependent on continuous oxygen, expressed concern about not receiving timely assistance, especially during dinner hours, and described the situation as distressing. Staff interviews corroborated these concerns, with multiple staff members indicating that staffing shortages were particularly acute on weekends due to frequent call-ins. Staff described being pulled in multiple directions, struggling to complete all required tasks and documentation within their shifts, and sometimes needing to stay late or finish charting the next day. One LPN noted that the staffing goal was not always met and suggested that having a dedicated admission nurse would alleviate some of the workload. The staff scheduler confirmed that staffing was based on the Facility Assessment and resident acuity, but also acknowledged that the number of staff scheduled did not always meet the identified requirements, and that medication technicians (MTs) were counted as CNAs on the schedule, despite not being listed in the Facility Assessment. A review of staffing schedules for the month of February showed that the facility was consistently short of the required number of licensed nurses and CNAs as outlined in the Facility Assessment. On numerous days, the facility was down by one or more licensed nurses and several CNAs, with the shortfalls ranging from half a CNA to as many as five and a half CNAs on certain days. These staffing deficits were confirmed by both the staff scheduler and facility leadership during interviews. The surveyor concluded that the facility did not provide staffing levels that met its own identified needs, as documented in the Facility Assessment, and that both residents and staff expressed ongoing concerns about inadequate staffing.
Failure to Report and Investigate Injury Following Incorrect Transfer
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of abuse, neglect, or injuries of unknown origin for a resident who experienced significant harm following an incorrect transfer. The resident, who had Parkinson's Disease and required an EZ stand with one-person assist for transfers, reported severe left knee pain after being transferred by a method not consistent with her care plan. The pain began after a pivot transfer was performed instead of using the required EZ stand, and the resident subsequently developed bruising, swelling, and was later found to have a left distal femur fracture. Despite the resident's complaints and the visible signs of injury, the facility did not report the incident to the Nursing Home Administrator or the State Agency as required by their abuse prevention policy. The facility's own policy mandates immediate reporting of any suspicion of abuse or serious bodily injury, including injuries resulting from failure to follow the care plan. However, the incident was not entered into the facility's grievance log or reported as a Facility Reported Incident (FRI) to the state, even though several staff members were aware of the situation soon after it occurred. Interviews with facility leadership revealed that the decision not to report was based on an abuse reporting algorithm intended for assisted living facilities, not skilled nursing facilities. The administration did not consider the incident to meet the criteria for willful intent, despite the resident's injury and subsequent death. The facility's investigation was delayed, and conflicting accounts from staff and the resident were cited as reasons for not reporting. The failure to follow the resident's care plan and the lack of timely reporting to the appropriate authorities constituted a violation of the facility's abuse prevention and reporting policies.
Failure to Timely Report Suspected Neglect and Injury of Unknown Origin
Penalty
Summary
A resident with Parkinson's Disease and a history of myocardial infarction was assessed to require an EZ stand and assist of one for transfers, as documented in the care plan. Despite this, the resident was transferred using a pivot transfer by a single staff member, contrary to the care plan instructions. Following this transfer, the resident complained of pain, swelling, and bruising to the left knee, which she reported began after being transferred without the EZ stand. The resident's condition declined both physically and cognitively after the incident, and she subsequently passed away at the facility. The facility's own policy requires immediate reporting of any suspected abuse, neglect, or injury of unknown origin to the Nursing Home Administrator and the State Agency, with specific timelines for reporting based on the severity of the injury. Despite multiple staff being aware of the resident's complaints, bruising, and decline, the incident was not reported to the administrator or the State Agency within the required timeframe. The responsible party for the resident expressed concerns to the facility, believing the resident had been dropped during the transfer, but these concerns were not communicated to the appropriate authorities as required. Interviews and record reviews revealed that the facility did not initiate a Facility Reported Incident (FRI) related to the transfer without the EZ stand, nor did they notify the State Agency. The Nursing Home Administrator stated that the incident was not reported because the facility followed an abuse reporting algorithm that did not consider the event as meeting the criteria for willful intent. However, surveyors noted that the algorithm used was not appropriate for skilled nursing facilities. The medical examiner's preliminary autopsy results indicated the cause of death was a fracture of the distal left femur, consistent with a fall or drop, further highlighting the failure to report the incident as required by policy and regulation.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician or physician extender at the required intervals, as outlined in their own policy and federal regulations. For one resident, there was only a single documented physician visit since admission, with all other visits conducted by nurse practitioners, and no evidence of alternating visits between the physician and physician extender. The facility was unable to provide documentation of additional physician visits or an explanation for the lack of alternating visits. Another resident was not seen by a physician within the required 60-day interval following the initial 90 days after admission. There was a gap of 128 days between physician visits, and after the most recent documented physician visit, there was another gap of 114 days without a physician assessment. The deficiency was identified through record review and confirmed in interviews with the Nursing Home Administrator and Director of Nursing, who were unable to provide additional documentation to support compliance with physician visit requirements.
Inadequate Supervision and Care Planning Leads to Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents, R3 and R2. R3, who has multiple medical conditions including multiple sclerosis and paraplegia, experienced a fall while receiving incontinent care from a CNA. The CNA reportedly guided R3 out of bed, but R3 stated that the CNA watched her roll out of bed, resulting in a laceration to the forehead and a right femur fracture. The facility did not conduct a thorough investigation into the incident, as there were no statements from the nurse who assessed R3 or from R3 herself, and no details about the bed's position or whether care plan interventions were in place at the time of the fall. Additionally, R3's care plan did not address the air mattress on the bed. R2, who has a history of cerebral infarction and is severely cognitively impaired, sustained multiple falls, one of which resulted in injury. The facility did not complete thorough investigations after each fall to determine the root cause. Some interventions established were not specific enough to prevent further falls. R2's care plan included interventions such as offering to be in common areas while awake and monitoring for changes in the ability to navigate the environment, but there was no documentation indicating whether these interventions were implemented or effective. The facility's policy on fall management requires assessing hazards and risks, developing a care plan to address these, and implementing appropriate interventions. However, the facility failed to adhere to this policy, as evidenced by the lack of thorough investigations and specific interventions for both R3 and R2. The deficiencies in supervision and care planning contributed to the accidents and injuries sustained by the residents.
Inadequate Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient nursing staff was provided to meet the needs of all residents, affecting their ability to maintain or attain their highest practicable physical, mental, and psychosocial well-being. Surveyors observed and recorded multiple instances of inadequate staffing levels, which were corroborated by interviews with residents and staff. Residents reported long wait times for call lights to be answered, with some waiting up to an hour or more. Staff members, including CNAs and LPNs, expressed concerns about being unable to complete their duties due to insufficient staffing, particularly on weekends and nights. Specific examples include a resident who reported having to wait 45 minutes to an hour for call lights to be answered and another resident who was not walked as required due to staff shortages. A CNA reported having to come in early to complete tasks and sometimes leaving essential duties unfinished. The facility's call light system showed delays in response times, with one instance of a call light not being answered for 25 minutes. Residents also reported that their concerns about staffing had been raised in Resident Council meetings but remained unaddressed. The facility's staffing records revealed that the number of CNAs on duty frequently fell short of the facility's assessed needs. For example, during a three-day period in October, the facility was consistently understaffed by three to five CNAs. This pattern continued throughout November, with the facility failing to meet staffing requirements on 17 out of 30 days. The Scheduling Coordinator confirmed that staffing was based on acuity and census, but acknowledged challenges in maintaining appropriate levels, particularly on weekends due to call-ins and the lack of incentive programs for staff retention.
Inconsistent Water Distribution to Residents
Penalty
Summary
The facility failed to ensure that water was consistently provided to residents, as required by their policy. The policy, dated September 2020, mandates that clean water pitchers or cups be filled with ice and water every shift and as necessary, with specific instructions for residents on thickened liquids or fluid restrictions. However, multiple residents reported that they only received water upon request, and some did not receive it at all. Observations by the surveyor confirmed the absence of water glasses in some residents' rooms, and staff interviews revealed inconsistencies in water distribution practices across different units. Several residents, including those with cognitive impairments, were affected by this deficiency. For instance, a resident with a BIMS score indicating severe cognitive impairment did not have a water glass in their room and reported not receiving water. Other residents, who were cognitively intact, also reported that water was not provided unless requested. Staff members provided varying accounts of water distribution, with some stating that water was passed out only when possible, and others indicating a lack of necessary supplies like cups. The Director of Nursing and other administrative staff were informed of these findings, but no explanation was provided for the inconsistency in water distribution.
Failure to Investigate Alleged Mistreatment
Penalty
Summary
The facility failed to thoroughly investigate an alleged violation of mistreatment involving a resident, identified as R1, who reported being yelled at and handled roughly by a Certified Nursing Assistant (CNA). The facility's policy mandates prompt and aggressive investigation of all reports and allegations of mistreatment, but in this case, there was no evidence of a formal investigation being conducted. The Assistant Administrator (AA-E) acknowledged being informed by R1's family member about the alleged mistreatment but did not document any investigation or take formal steps to address the issue. R1, who had moderate cognitive impairment and multiple medical conditions including hemiplegia, diabetes, and epilepsy, was admitted to the facility and later discharged. During the survey, R1's family member reported to the surveyor that a CNA was rough and yelled at R1, and this was communicated to AA-E. However, AA-E did not recall any specific details about the alleged mistreatment and only provided a verbal warning to the CNA without documenting the incident or conducting a formal investigation. The surveyor's review of the facility's grievance report revealed no documentation of the alleged mistreatment, except for a separate grievance about a missing phone. Despite being informed of the allegations, AA-E did not initiate a formal investigation or document any actions taken to address the concerns. The lack of documentation and formal investigation into the alleged mistreatment constitutes a deficiency in the facility's compliance with its abuse policy.
Failure to Ensure Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications ordered on an as-needed (PRN) basis. Specifically, a resident with multiple medical conditions, including multiple sclerosis, diabetes mellitus, and anxiety disorder, was prescribed Lorazepam 0.5 mg every four hours PRN for anxiety without an end date. This prescription was noted upon the resident's readmission to the facility, as documented in the hospital discharge papers dated 11/10/24. Upon review of the resident's physician orders on 12/2/24, the surveyor found that the order for Lorazepam did not include an end date. When questioned, the Med Tech indicated that RNs were responsible for ensuring stop dates for PRN psychotropic medications. The Director of Nursing (DON) later confirmed that the nurse who enters the order is responsible for including the stop date. The surveyor noted that an end date was added to the order on 12/2/24 by the Regional Nurse Consultant, following the surveyor's initial review.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident received their prescribed medication, Oxycodone 5mg, as ordered by the physician on multiple occasions. The resident, who has a history of chronic pain syndrome, polyosteoarthritis, and anxiety disorder, was prescribed Oxycodone to manage pain related to a wedge compression fracture. Despite the facility's policy requiring medications to be reordered in advance to prevent lapses in therapy, the resident did not receive the medication on several dates across July, September, October, and November 2024. The deficiency was attributed to a breakdown in the medication reordering process. Nursing staff were responsible for reordering medications when a two-day supply remained, but there were instances where the medication was not available due to issues with obtaining a new prescription from the nurse practitioner. The facility's electronic medication administration record (eMAR) and nurses' notes documented multiple instances where the medication was unavailable, pending delivery, or awaiting authorization from the nurse practitioner. The resident reported experiencing significant pain when the medication was not administered, rating it as "off the chart." Interviews with facility staff, including registered nurses, licensed practical nurses, and the Director of Nursing, revealed that there were challenges in obtaining timely prescriptions for narcotic medications. Staff indicated that they attempted to reorder medications and contact the nurse practitioner for new prescriptions, but there were delays and uncertainties in the process. The Director of Nursing acknowledged the struggle in obtaining scripts and noted that the facility was dependent on the nurse practitioner or medical doctor to provide the necessary prescriptions.
Failure to Consult Physician After Resident's Significant Condition Changes
Penalty
Summary
The facility failed to promptly consult with the resident's physician when a resident (R414) experienced significant changes in condition following unwitnessed falls on 10/27/23 and 10/29/23. Despite signs consistent with a head injury, including altered mentation, pain, vomiting, and cognitive impairment, the facility did not seek guidance from the resident's primary physician, the Medical Director, or the Hospice provider. The resident's condition continued to deteriorate, leading to his eventual passing. The facility's policy on Change in Condition clearly outlines the procedures for notifying physicians and responsible parties of any changes in a resident's condition, which were not followed in this case. The resident, R414, had a complex medical history upon admission, including dementia, depression, panic disorder, anxiety, a-fib, obstructive uropathy, and failure to thrive. R414 required extensive assistance with daily activities and was at high risk for falls due to limited mobility and impaired balance. Despite being under hospice care for Monoclonal Gammopathy, the facility did not appropriately address the significant changes in R414's condition that were unrelated to his hospice diagnosis. The staff failed to recognize the urgency of the situation and did not escalate the matter to the resident's physician in a timely manner. Throughout the documented incidents, including R414's complaints of pain, altered mentation, weakness, and other concerning symptoms, there was a lack of communication and coordination between the facility staff, hospice provider, and the resident's physician. The facility's failure to involve the physician in assessing and managing R414's changing condition, especially after the falls and head injury, resulted in a delay in appropriate medical intervention. The staff's reliance on hospice directives without consulting the physician directly contributed to the inadequate response to R414's deteriorating health status.
Deficiency in Fall Prevention and Post-Fall Protocols
Penalty
Summary
The report highlights a concerning deficiency in a nursing home's care related to the prevention of accidents and falls, particularly in the case of resident R414. R414, admitted with multiple diagnoses including dementia and anxiety, was assessed as high risk for falls upon admission. Despite this risk assessment, the facility failed to prevent two unwitnessed falls that resulted in significant injuries to R414, including head trauma and cognitive impairment. The facility's lack of post-fall investigations after each incident and failure to revise the care plan to address the identified risks contributed to the ongoing hazards faced by R414. The first fall occurred when R414 was found on the bathroom floor with altered mentation and an inability to orient himself. Subsequent falls included reaching for a call light that was out of reach, leading to head injuries and cognitive changes. The report notes a lack of proper documentation and notification to the medical team regarding R414's changing condition, including signs of weakness, altered speech, and cognitive decline. Despite the facility's policies outlining fall prevention measures and post-fall protocols, these were not effectively implemented in R414's case, resulting in repeated incidents and ultimately, R414's passing.
Communication and Coordination Gaps in Resident Care Management
Penalty
Summary
The deficiency identified in the report revolves around the facility's failure to ensure proper collaboration and communication processes between hospice, the facility, the physician, and the power of attorney for a resident (referred to as R414) with multiple complex medical conditions. R414 experienced significant changes in condition, including unwitnessed falls, altered mentation, slurred speech, weakness, and other concerning symptoms. Despite these changes, there were lapses in updating the physician, power of attorney, and ensuring coordination of care between hospice and the facility. The facility staff did not consistently relay critical information about R414's condition, leading to a lack of comprehensive care planning and decision-making. The report highlights instances where the facility did not adequately inform hospice, the physician, or the power of attorney about R414's deteriorating condition, such as head injuries, altered mentation, and physical decline. There were delays in notifying the appropriate parties about significant changes, including falls and cognitive impairments, which impacted the continuity of care and decision-making processes. The lack of timely and accurate communication between the facility, hospice, and other involved parties resulted in a failure to address R414's evolving care needs effectively.
Failure to Monitor Skin Under Immobilizer Leads to Stage 4 Pressure Ulcer
Penalty
Summary
The facility did not ensure they provided the necessary care, consistent with professional standards of practice, to prevent the development of pressure ulcers for a resident who was at high risk. The resident returned to the facility following surgical repair to the left knee and was required to wear an immobilizer for six weeks. The facility failed to monitor the resident's skin under the immobilizer, leading to the development of a stage 4 pressure ulcer on the back of the left lower leg. The resident had a history of multiple medical conditions, including a recent surgery, decreased mobility, and a need for staff assistance with activities of daily living. Despite the hospital discharge instructions and physician orders, the facility did not conduct regular skin assessments under the immobilizer. The Director of Nursing confirmed that nursing staff should have been checking the skin each shift, but there was no documentation to support that these checks were being performed. The pressure ulcer was discovered during a random skin check by the Director of Nursing, not by the regular staff. The facility's assessment indicated that the pressure ulcer was unavoidable due to the non-removable brace, but this was contradicted by the fact that staff were reportedly washing and applying lotion to the area. The facility's documentation did not clarify whether the immobilizer was removed during skin checks, and there was no evidence that the physician's order regarding skin checks under the immobilizer was clarified.
Infection Control Deficiencies
Penalty
Summary
The facility did not ensure all staff exposed to COVID-19 were properly fit tested for an N95 mask to prevent the spread of infection. Upon entering the facility for the Recertification and Complaint Survey, the surveyor identified a resident with COVID-19 and observed that not all staff were up to date with their N95 fit testing. The facility was behind on fit testing and did not have a clear record of which staff were currently up to date. Despite the facility's efforts to fit test staff annually in March, only 10 out of 30 staff members who worked with COVID-positive residents were up to date on their fit testing at the time of the survey. The facility's plan to fit test staff when they come to pick up paychecks was noted, but it was clear that the current fit testing status was inadequate for infection control purposes. The facility's policy required staff to wear full PPE, including N95 respirators, when providing care to COVID-positive residents, but this was not consistently enforced due to the lapse in fit testing. The surveyor's review of the facility's infection control program and interviews with staff revealed that the facility was aware of the issue but had not yet resolved it effectively. The facility's failure to ensure proper fit testing for all staff exposed to COVID-19 posed a risk of infection spread among residents and staff. Additionally, the facility did not maintain a sanitary environment for a resident with a Foley catheter. The surveyor observed the resident's catheter bag and tubing laying on the floor under the wheelchair and being dragged during transport. The facility's policy on indwelling catheters required the catheter bag to be kept off the floor and covered during transport, but this was not followed. The resident's medical record did not contain a comprehensive plan of care for the indwelling catheter, and staff interviews confirmed that the catheter bag should not touch the floor. The facility's failure to maintain the catheter bag in a sanitary manner increased the risk of infection for the resident. The surveyor's observations and interviews with staff highlighted the facility's deficiencies in infection prevention and control, both in terms of N95 mask fit testing and Foley catheter maintenance. These deficiencies were documented and shared with the facility's administration during the survey process.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility did not ensure residents received the required written notice information related to their transfers out of the facility. This deficiency was observed in seven residents who were transferred to the hospital. The required transfer notice, which should include information on appeal rights, the contact details of the State Long-Term Care Ombudsman, and other relevant agencies, was not provided to any of these residents. The Assistant Nursing Home Administrator (ANHA) was unaware of the full notice requirements and indicated that the facility was in the process of updating their forms and policies to comply with these requirements. However, at the time of the survey, the facility did not have a policy and procedure related to the transfer notice requirement in place. For instance, one resident (R108) was transferred to the hospital after a fall and subsequently chose not to return to the facility. The medical record did not contain evidence that the resident received the required written notice information with their transfer. Similarly, another resident (R38) was transferred to the hospital twice due to medical conditions, but the transfer forms provided did not include information on how to appeal the transfer or contact details for the Ombudsman. The facility's Assistant Nursing Home Administrator confirmed that the bed-hold form used was outdated and did not include the necessary information. Other residents, such as R25, R77, R54, R85, and R65, also did not receive the required transfer notices with the necessary information. The facility was unable to provide evidence that these notices were given, and the forms used lacked critical details such as appeal rights and contact information for relevant agencies. Despite the facility's acknowledgment of the issue and ongoing efforts to update their forms, the deficiency remained unaddressed at the time of the survey, as evidenced by the lack of proper documentation in the residents' medical records.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility did not ensure that an allegation of an injury of unknown source for a resident was reported immediately to the State Survey Agency within the required 2-hour timeframe. The resident experienced pain in the left knee, and an X-ray revealed a left distal femur fracture. Despite the severity of the injury, the facility failed to report the injury within the mandated timeframe and did not submit the results of their investigation within 5 working days as required by policy. The resident, who has a history of epilepsy, muscle weakness, anxiety disorder, dysphagia, history of falling, and hemiplegia, was seen by a Nurse Practitioner for routine maintenance and complained of left knee pain. An X-ray was ordered, and the results indicated a fracture. The resident was subsequently admitted to the hospital for surgical repair. The Director of Nursing (DON) was unable to provide evidence that the injury was pathological and did not report the injury to the State Survey Agency, believing it was unnecessary. Further review of the resident's medical and hospital records showed no documentation supporting the claim that the fracture was pathological. The DON admitted to not submitting a self-report investigation and was unable to locate staff statements regarding the incident. The lack of documentation and timely reporting indicates a failure to comply with regulatory requirements for reporting and investigating injuries of unknown sources.
Lack of Individualized Comprehensive Care Plans
Penalty
Summary
The facility did not ensure that residents had individualized comprehensive care plans. This deficiency was observed in two residents out of 23 reviewed. Resident 85 was admitted with an indwelling catheter but did not have a comprehensive care plan addressing catheter care. Despite the presence of physician orders for catheter management, the resident's medical records lacked a care plan for bowel and bladder care or indwelling catheter care. Interviews with the RN, Resident Care Coordinator, and DON confirmed that the care plan should have included these interventions, but it was an oversight during the review of hospital discharge paperwork and subsequent care plan updates. Resident 81 was admitted with a diagnosis that included the use of anticoagulant medication. However, there was no comprehensive care plan with individualized interventions to monitor the anticoagulant therapy. The resident's medical records showed that a care plan for anticoagulant use was initiated and resolved on the same day, leaving no active care plan for ongoing monitoring. Interviews with the Resident Care Coordinator and DON confirmed that an anticoagulant therapy care plan should have been included but was missed due to a transition in staff responsibilities. The surveyor shared concerns with the Nursing Home Administrator, DON, and Assistant Nursing Home Administrator regarding the lack of appropriate care plans for both residents. No additional information was provided by the facility to address these concerns.
Failure to Ensure Urology Follow-Up for Resident with Indwelling Catheter
Penalty
Summary
The facility did not ensure that a resident with an indwelling catheter received the necessary consult services. The resident, who was initially admitted without an indwelling catheter, was hospitalized due to a change in condition and returned with a catheter due to urinary retention. Despite hospital discharge instructions to follow up with urology for a voiding trial, the facility failed to arrange this follow-up. The resident's nurse practitioner's notes indicated multiple failed voiding trials and the need for a urology consult, but no documentation was found to confirm that this follow-up occurred. The Assistant Director of Nurses confirmed that the urology referral was canceled due to a subsequent hospital stay, and no new referral was requested by the facility. The surveyor observed the resident with an indwelling catheter and noted that the resident was unaware of the reason for its use. The facility's policy required assessment for catheter removal as soon as possible, but this was not adhered to. The Director of Nursing incorrectly stated that the resident was admitted with the catheter, despite documentation showing otherwise. The surveyor's findings highlighted a lack of proper follow-up and communication regarding the resident's catheter management, leading to the deficiency noted in the report.
Failure to Properly Assess and Document Bed Rail Use
Penalty
Summary
The facility did not ensure that a resident (R82) was properly assessed for the use of bed rails, nor did it have evidence that the risks and benefits were discussed with the resident or their representative. R82 was admitted for short-term rehabilitation with multiple diagnoses, including severe cognitive impairment and physical disabilities. Despite an assessment indicating that side rails were not appropriate for R82, the resident's bed was observed to have fixed grab bars, which are considered side rails. The facility's policy requires a side rail assessment upon admission, readmission, significant change, and annually, but this was not adhered to in R82's case. Interviews with facility staff revealed inconsistencies in the communication and documentation of side rail assessments. The Assistant Director of Nursing (ADON) confirmed that enabler bars are considered side rails and that assessments are typically completed by floor nurses. However, there was no clear process for communicating the results of these assessments. The Therapy Director stated that therapy did not recommend side rails for R82, and the Building Manager could not verify when the enabler bars were installed or removed. The grab bars were eventually removed from R82's bed, but this action was not documented or communicated effectively, highlighting a lapse in the facility's adherence to its own policies and procedures.
Insufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility did not ensure sufficient nursing staff was available to provide nursing and related services to assure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being. Residents voiced concerns about insufficient staff to care for their needs, and the facility was identified as having consistently low weekend staffing on the Staffing Data Report submitted to CMS from October 1, 2023, through December 31, 2023. Staff also indicated there were not enough staff on the unit to assist with residents' cares and needs. The facility's algorithm for determining the number of CNAs needed based on total census was not met on multiple occasions, leading to a shortage of CNAs on various days in December 2023, as documented by the surveyor's review of the daily staffing schedules and resident council notes. The facility's daily staffing schedule often fell short of the required number of CNAs as per their algorithm. For example, on December 31, 2023, with a census of 114 residents, the facility was short by 7 CNAs. Similar shortages were noted on other days, such as December 30, 2023, December 24, 2023, December 23, 2023, December 17, 2023, and December 16, 2023. The Scheduling Coordinator confirmed that the facility struggled with low weekend staffing and did not always meet the required number of CNAs. Additionally, the acuity of the residents was not considered when calculating the staffing needs, further exacerbating the issue. Residents consistently expressed concerns about low staffing during resident council meetings, and staff reported that low staffing was an ongoing issue. The surveyor observed a resident's call light active for 15 minutes, indicating delayed response times due to insufficient staffing. The facility's performance improvement plan (PIP) to address low staffing concerns was reviewed, but it lacked specific start or completion dates for most action items, indicating a lack of urgency in addressing the staffing deficiencies.
Failure to Ensure Proper Use and Documentation of Psychotropic Medications
Penalty
Summary
The facility did not ensure that residents were not given psychotropic drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. For Resident 25, the facility failed to implement a gradual dose reduction (GDR) for Mirtazapine, an antidepressant medication, despite recommendations from the pharmacist and behavior management team. The resident's Power of Attorney (POA) declined the GDR, and the facility did not document the refusal properly or attempt another GDR within the required timeframe. Additionally, a progress note from the Nurse Practitioner (NP) recommending the continuation of the current dose was not found in the resident's medical record, raising concerns about documentation practices and adherence to GDR protocols. Resident 103 was prescribed PRN Lorazepam, a sedative/antianxiety medication, without a documented rationale from the physician to extend its use beyond 14 days. The resident's care plan included the use of Lorazepam as part of a hospice comfort care package, but the PRN order did not have a stop date, violating regulations that limit PRN use of psychotropic drugs to 14 days. The issue was only addressed after the surveyor raised concerns, and a new order was entered with a 14-day limit. Resident 81 was prescribed Primidone, an anticonvulsant, without a clear indication of use. The medication administration record (MAR) incorrectly listed seizures as the reason for the prescription, despite the resident not having a diagnosis of seizures. Upon review, it was clarified that the resident was taking Primidone for essential tremors, and the order was subsequently modified. This discrepancy highlights issues with accurate documentation and the need for proper diagnosis alignment with prescribed medications.
Failure to Display Required Information
Penalty
Summary
The facility did not ensure the required posted information was displayed in the main entrance, lobby area, and all six units, potentially affecting all 117 residents. The missing information included a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit. Additionally, there was no statement indicating that residents may file a complaint with the State Survey Agency concerning any suspected violations of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property, and non-compliance with advanced directives. On multiple occasions, the surveyor observed the absence of the required postings in the main entrance, lobby area, and all six units. When interviewed, the Assistant Nursing Home Administrator and the Administrator were unaware that the postings were missing. The Director of Nurses suggested that the postings might have been removed due to remodeling. The Nursing Home Administrator later provided a sheet of paper with the required postings, but it contained incorrect information and lacked the necessary statements related to complaints, abuse, advanced directives, and the correct State Agency office. The Nursing Home Administrator acknowledged the issue and indicated they were working on it.
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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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