Amethyst Health Of Wausau
Inspection history, citations, penalties and survey trends for this long-term care facility in Wausau, Wisconsin.
- Location
- 1010 E Wausau Ave, Wausau, Wisconsin 54403
- CMS Provider Number
- 525405
- Inspections on file
- 38
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 37 (4 serious)
Citation history
Health deficiencies cited at Amethyst Health Of Wausau during CMS and state inspections, most recent first.
Multiple residents experienced misappropriation of their funds when payments intended for their care were deposited into an unauthorized account controlled solely by a business office manager, who used the funds for personal expenses. Families and residents reported ongoing issues with missing payments, unexplained billing, and inability to access their money, while facility staff failed to promptly investigate or report these concerns, leaving residents at risk of financial exploitation.
A facility failed to promptly report suspected misappropriation and exploitation of resident funds to authorities after discovering unauthorized withdrawals and questionable account activity managed by a business office manager. Multiple residents and their families experienced unexplained billing issues, missing payments, and depleted accounts, while staff concerns and evidence of possible forgery were not reported as required. The deficiency resulted in a finding of immediate jeopardy.
The facility did not thoroughly investigate multiple allegations of misappropriation and exploitation of resident funds, despite evidence of suspicious financial activity and concerns raised by residents, families, and staff. Key staff were aware of the issues but were directed not to report them to authorities or conduct a full investigation, resulting in continued financial discrepancies and lack of protection for affected residents.
Facility administration failed to implement effective systems for managing resident finances, resulting in unmonitored accounts, unauthorized withdrawals, and inaccurate billing. A business office manager maintained a hidden account used for various purchases and withdrawals, while residents and their families experienced missing receipts, unexplained balances, and continued withdrawals after discharge. The administration did not follow required reporting or investigation procedures for suspected misappropriation, and necessary policies and tools were lacking.
A registered nurse was hired without the required background checks, including the Background Information Disclosure, Department of Justice response, and Government Findings report, as mandated by facility policy. Review of personnel files and staff interviews confirmed that these checks were not completed prior to the nurse starting work, and several other staff files were also found to be missing required documentation.
A resident was re-admitted after hospitalization and removal of an indwelling catheter, but staff did not complete or document comprehensive assessments or monitoring as required by professional standards. Facility leadership confirmed there was no current policy on assessments and documentation, and acknowledged the resident was not appropriately assessed or monitored after re-admission.
Two housekeeping staff members did not receive mandatory infection control training since hire, as confirmed by staff interviews and record review. The NHA acknowledged the absence of a policy and documentation for such training, potentially affecting all residents.
Three residents who were either discharged or deceased had open trust fund accounts with remaining balances that were not returned to them or their representatives within the required 30-day period. The facility lacked a policy for timely return of these funds, and the issue was confirmed through record review and staff interview.
A resident with severe cognitive impairment was identified as an elopement risk and fitted with a Wander Guard device, despite the most recent risk assessment indicating no elopement risk. The device was applied without a physician's order or written consent, and only verbal consent was obtained from the resident's POA. Staff confirmed that no updated risk assessment or proper documentation was completed prior to the use of the Wander Guard.
A resident with an unstageable pressure ulcer and a history of diabetes repeatedly refused wound care treatments, dressing changes, and compliance with repositioning protocols. Although these refusals were documented in nursing notes, the care plan was not updated to reflect the resident's choices or the facility's response, contrary to facility policy.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as observed and documented by surveyors.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with stage four pressure injuries had a dressing change performed by an LPN who failed to keep clean and dirty areas separate on the barrier and brought the treatment cart into the room, contrary to facility expectations. Another resident with a suprapubic catheter was observed with the drainage bag touching the floor on two occasions, despite staff acknowledging that this practice does not meet infection control standards.
A resident admitted with a stage 2 sacral pressure ulcer did not receive a comprehensive skin assessment upon admission. Instead, an LPN performed only a basic assessment, missing the sacral wound, and a full assessment by an RN was delayed for two days. This resulted in a lack of documentation to track the pressure injury's progression.
A resident requiring close supervision while eating was left unattended with food, contrary to care plan and speech therapy recommendations. An LPN left the resident alone after administering medication, assuming a CNA would assist shortly. The CNA later expressed surprise at the lack of supervision, indicating a communication lapse. Interviews confirmed the need for supervision to prevent choking, highlighting a failure in protocol adherence.
A resident experienced inadequate pain management due to inconsistent pain assessments and a lack of individualized care planning. Despite reporting significant pain in the legs and back, the resident's care plan only mentioned migraines and did not include scheduled pain medications or non-pharmacological interventions. Interviews with staff revealed communication gaps and an inability to adjust the pain management plan, leading to unmet pain needs.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a Kennedy terminal ulcer. A CNA was observed performing personal care without a gown, despite EBP signage on the door. The CNA misunderstood the need for EBP due to a communication lapse during the morning report. The DON confirmed EBP was reinstated after the wound reopened, but this was not communicated to staff, leading to the deficiency.
The facility failed to establish a governing body responsible for implementing policies, leading to significant financial arrears affecting resident care. Various service providers have ceased services due to unpaid invoices, and financial concerns are not regularly discussed in meetings. The facility is transitioning to a new financial management service.
Failure to Prevent and Investigate Misappropriation of Resident Funds
Penalty
Summary
The facility failed to ensure that residents were free from misappropriation and exploitation of their funds. Multiple instances were identified where resident payments intended for care and room charges were deposited into a bank account that only the Business Office Manager (BOM) had access to. This account was unknown to other facility leadership and was used for personal purchases, including cash withdrawals, restaurant, and store charges. The BOM was the sole authorized user of this account, and the facility administrator only became aware of its existence after reviewing a bank statement. The administrator's subsequent investigation revealed that resident checks and insurance payments were being deposited into this unauthorized account, and the BOM closed the account after being questioned. Several residents and their families reported ongoing issues with missing funds, unexplained billing, and inability to access or account for their money. For example, one resident's family continued to receive bills despite having made substantial payments, and another resident was at risk of losing their place at an assisted living facility due to missing Social Security payments. In some cases, checks written from residents' personal checkbooks had signatures that did not match the residents' handwriting, and funds were withdrawn from resident accounts after discharge. Facility staff, including the social worker and administrator, expressed concerns about the whereabouts of resident funds and suspected misappropriation, but these concerns were not promptly or thoroughly investigated or reported to the state agency or law enforcement as required. The facility did not have or could not provide policies related to accounts receivable or resident funds when requested by the surveyor. Interviews with staff and family members revealed a lack of communication and transparency regarding the handling of resident funds. The administrator and other leaders failed to notify affected residents or their representatives about the suspected misappropriation, and there was no evidence of a thorough internal investigation prior to the survey. The facility's failure to act on suspicions of misappropriation and to report these incidents in a timely manner left residents at continued risk of financial exploitation and resulted in a finding of immediate jeopardy.
Removal Plan
- The NHA and member of a governing body conducted an audit of past residents' funds. Credits will be made to families who are owed. The NHA and member of the governing body reviewed the petty cash policy and implemented it.
- The Director of Nursing (DON), Social Service Director (SSD) and Minimum Data Set (MDS) nurse/care plan nurse will review clinical documents to identify any negative outcome that may have resulted from the alleged deficiency. The following documents were reviewed: NAR report, 24-hour summary, order report listing, incident report portal, transfer/discharge log, concern log and resident council minutes.
- The DON/SSD/Nurses will complete assessment of all residents to identify any negative psychosocial outcomes or worsening of overall condition that may have resulted from the alleged deficiency. The attending physician/Nurse Practitioner (NP) of the resident will be notified of any negative findings.
- The NHA/SSD/DON will conduct interviews of interviewable residents to identify if they have any concern related to mishandling, misused and/or misappropriation of their funds. Any identified concern will be reported to the state agency and law enforcement, and investigation will be conducted. For residents who are not able to participate in the interviews, the NHA/SSD/DON will interview the resident representatives.
- The corporate BOM will also audit all residents' status of benefits (Medicaid and Managed Care) to identify any concern. An investigation will be conducted if any concern is identified.
- Any identified misappropriation of residents' funds and exploitation will be reported to the NHA, state agency and law enforcement.
Failure to Report Suspected Misappropriation and Exploitation of Resident Funds
Penalty
Summary
The facility failed to immediately report suspected misappropriation and exploitation of resident funds to the State Agency and local authorities upon discovery. The Nursing Home Administrator (NHA) identified concerns after reviewing a bank statement for an account under the facility's name, which was unknown to the NHA. The statement revealed significant cash withdrawals and a money order, and the bank confirmed that the Business Office Manager (BOM) had a checkbook and debit card for this account. The NHA suspected that resident payments intended for care and room fees were being deposited into this unauthorized account rather than the facility's Resident Fund Management System. Despite these findings, the NHA was instructed by the Director of Operations (DOO) not to report the concerns to the State Agency or police department. Multiple residents were affected by these actions. For example, one resident's family reported ongoing billing issues despite making substantial payments, and another resident's family was unable to determine the whereabouts of Social Security income. The Social Worker and NHA also expressed concerns about residents with significant funds who suddenly had negative balances or depleted accounts, and there were suspicions of forged signatures on personal checks. An insurance check was also deposited into the unauthorized account, with no clear indication of which resident it was intended for. These concerns were not reported to the appropriate authorities as required by facility policy and federal regulations. Interviews with staff and family members confirmed ongoing concerns about the handling of resident funds, lack of transparency, and the absence of timely reporting to authorities. The BOM resigned after a disciplinary meeting, and the NHA eventually contacted the police and State Agency only after being prompted by the surveyor. The facility was unable to provide policies for accounts receivable and payable when requested by the surveyor, and the failure to report the suspected misappropriation and exploitation of resident funds resulted in a finding of immediate jeopardy.
Removal Plan
- The DON/SSD/Nurses will complete assessment of all residents to identify any negative psychosocial outcomes or worsening of overall condition that may have resulted from the alleged deficiency. The attending physician/NP of the resident will be notified of any negative findings.
- The NHA/SSD/DON will conduct interviews of interviewable residents to identify if they have any concern related to mishandling, misused and/or misappropriation of their funds. Any identified concern will be reported to the state agency and law enforcement, and investigation will be conducted. For residents who are not able to participate in the interviews, the NHA/SSD/DON will interview the resident representatives.
- The corporate business office manager will audit all residents' status of benefits (Medicaid and Managed Care) to identify any concern. An investigation will be conducted if any concern is identified. Any identified misappropriation of residents' funds and exploitation will be reported to the NHA, state agency and law enforcement.
- The NHA/DON will provide training to the department heads (Activities, SSD, BOM, Dietary Manager, Therapy Director, Environmental Services and Maintenance staff) related to the intent of F609, facility policy related to Abuse, Neglect, Exploitation and Misappropriation, focusing on the reporting requirements and responsibility of the staff to misappropriation of resident property, and exploitation to the state agency and police department.
- The DON/NHA/trained department head will provide training to all staff about reporting allegations of abuse, neglect and misappropriation to the Administrator/DON. The staff members who are not available will receive their education prior to starting their shift upon return to work.
Failure to Investigate Alleged Misappropriation and Exploitation of Resident Funds
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of misappropriation and exploitation of resident funds, affecting at least five residents. The Nursing Home Administrator (NHA) discovered a bank account under the facility's name, which was unknown to them, containing suspicious withdrawals and transactions. The Business Office Manager (BOM) was identified as having access to this account, and there were indications that resident payments intended for care and room and board were deposited into this account and potentially used for personal purposes. Despite these findings, the NHA was directed by the Director of Operations (DOO) and the facility owner not to report the incident to the State Agency or law enforcement, and no thorough investigation was initiated at that time. Several residents and their families reported concerns about missing payments, uncredited funds, and unexplained depletion of resident accounts. For example, one resident's family received bills despite having made payments, another resident's Social Security checks were unaccounted for, and a resident with severe cognitive impairment had checks written from their account with signatures that did not match their handwriting. In each of these cases, the concerns were either not investigated or only minimally reviewed, with no follow-up to determine the extent of the misappropriation or to identify all affected residents. Interviews with staff, residents, and family members confirmed that concerns about financial discrepancies were raised but not addressed. The NHA acknowledged being aware of the issues and sharing them with upper management, but was instructed not to alert authorities or conduct a full investigation. The lack of action allowed the misappropriation and exploitation to continue, and the facility did not ensure that residents were protected or that a thorough analysis of the situation was conducted, as required by facility policy.
Removal Plan
- Provide training to the NHA, DON, new BOM and members of the governing body about the intent of F610 and their responsibility to identify and investigate allegations of misappropriation of residents' funds.
- Conduct interviews of interviewable residents to identify concerns related to mishandling, misused and/or misappropriation of their funds. Report any identified concern to the state agency and law enforcement, and conduct an investigation. For residents unable to participate, interview resident representatives.
- Audit all residents' status of benefits (Medicaid and Managed Care) to identify concerns. Conduct an investigation if any concern is identified. Report any identified misappropriation of residents' funds and exploitation to the NHA, state agency and law enforcement.
- Complete assessment of all residents to identify any negative outcome. Notify the attending physician/NP of any negative findings.
- Initiate investigations while ensuring residents are protected from further misappropriation of property and exploitation.
- Provide training to the RDO, NHA, DON, and members of the governing body related to the intent of F610, facility policy related to investigation of allegations of misappropriation of resident property and exploitation, and staff responsibility to assure thorough investigation and implement measures to prevent further mishandling of finances and/or exploitation and to safeguard residents' finances.
- Provide training to department heads (Activities, SSD, BOM, Dietary Manager, Therapy Director, Environmental Services and Maintenance staff) related to the intent of F610, facility policy related to investigation of allegations of misappropriation of resident property and exploitation, and staff responsibility to assure thorough investigation and implement measures to prevent further mishandling of finances and/or exploitation and to safeguard residents' finances.
- Provide staff with training about their responsibility to participate/cooperate with the administration when conducting an investigation. Staff who are not available will receive their education prior to starting their shift upon return to work.
Failure to Safeguard and Manage Resident Finances
Penalty
Summary
Facility administration failed to ensure effective and secure management of resident finances, resulting in a lack of oversight and accountability for resident accounts. The Business Office Manager (BOM) maintained a bank account in the facility's name, complete with a debit card and checkbook, which was unknown to the Nursing Home Administrator (NHA) and other management staff. This account was used for various cash withdrawals and purchases, with no effective system in place to determine the purpose or beneficiary of these transactions. Additionally, there was no tracking system for payments received from residents or their representatives, and the administration did not hold the BOM or third-party billing company accountable for the safe and accurate handling of resident funds. Multiple instances were identified where resident funds were mishandled. For example, a check from a resident was deposited into the undisclosed account after the resident had been discharged, and family members reported inaccurate statements, missing receipts, and unexplained balances. In one case, a resident's Social Security payments continued to be withdrawn for care costs after discharge, and the managed care organization (MCO) responsible for payment did not receive the funds, putting the resident at risk of losing benefits. The BOM was listed as the authorized user on the resident's account, preventing the MCO from making necessary changes without police involvement. These issues were compounded by poor communication with the third-party billing company and a lack of transparency with residents and their representatives. The administration did not follow regulations or facility policy regarding the reporting and investigation of suspected misappropriation or exploitation of resident finances. Despite being made aware of potential fraud and misappropriation, upper management advised against submitting a facility-initiated report to the State Agency or police, and a thorough investigation was not conducted. Policies and procedures for accounts payable and receivable were not provided when requested, and staff lacked the necessary education and tools to properly manage resident funds. These failures led to a finding of immediate jeopardy, as residents were placed at risk for misappropriation and exploitation of their funds.
Removal Plan
- The compliance consultant will provide the NHA, DON, new BOM and members of the governing body training about the intent of F835 and their responsibility to operate and manage the facility efficiently and effectively to ensure that the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The training will also include review of their responsibility to prevent abuse, including misappropriation of resident property and exploitation, identifying, investigating and protecting residents from allegations of abuse and exploitation that has the potential to cause serious injury, harm, impairment, or death. To identify any negative outcome, the DON/SSD/Nurses will complete assessment of all residents. The attending physician/NP of the resident will be notified of any negative findings.
- The NHA and members of the governing body, NHA and Regional Director of Clinical Services will discuss the alleged deficiency and the corrective actions which are described in this plan of removal. The Administrator will notify the Medical Director of the alleged deficiency and immediate actions described in this plan of removal.
- To prevent the recurrence of the alleged deficiency, safeguard and track resident financials to include accounts payable and accounts receivables, an updated process will be implemented. The NHA/corporate regional representative will provide training to the new BOM about the new process. NHA to review and initial/sign off on all new accounts.
- Deposit process will be reviewed and updated to include two signers to accept checks and provide receipt with signatures. Both signers then log receipt of check on the Facility Check Receipt Log. Log will be reviewed weekly by facility NHA.
- Resident fund requests will be reviewed and updated: BOM makes withdrawal from resident's RFMS account and puts the money into the facility's RFMS Petty Cash account. BOM provides resident with requested money at the facility out of the RFMS Petty Cash box. RFMS Petty Cash box will be counted by the NHA and BOM weekly to ensure accuracy. Once RFMS Petty Cash box reaches a certain threshold (set by the NHA based on facility needs), a replenishment check will be requested. RFMS Petty Cash box will be counted. Receipts, G/L log and count will be sent to third-party billing office. Replenishment check will be issued to facility. Replenishment check will then be cashed at local bank. Funds will be counted at facility by two employees. Funds will then be placed back into the RFMS Petty Cash box.
- The policies and procedures related to administration of the facility will be reviewed by the NHA, DON, Medical Director and a representative of the governing body. The compliance consultant will provide the NHA, DON and members of the governing body training about administration of the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. It will be emphasized that the NHA and DON are accountable for all the programs and services in the facility to meet the needs of the residents who reside in the facility. The Administrator and DON are accountable for planning, coordinating and managing all services, including protection of residents from misappropriation of property and exploitation, meeting the reporting and thorough investigation requirements of any allegation related to misappropriation of resident property and exploitation, and are responsible for the overall direction, coordination and evaluation of all care and services provided to the residents in the facility.
- The NHA/DON will provide training to the department heads (Activities, SSD, BOM, Dietary Manager, Therapy Director, Environmental Services and Maintenance staff) about the intent of F835 and their responsibility to operate and manage the facility efficiently and effectively to ensure that the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The training will also include review of their responsibility to prevent abuse, including misappropriation of resident property and exploitation, identifying, investigating and protecting residents from allegations of abuse and exploitation that has the potential to cause serious injury, harm, impairment, or death.
Failure to Complete Required Employee Background Checks Prior to Employment
Penalty
Summary
The facility failed to implement its policies and procedures regarding the screening of employees for a prior history of abuse, neglect, exploitation, or misappropriation of resident property. Specifically, one of thirteen employee files reviewed, belonging to a registered nurse, did not contain a completed Background Information Disclosure (BID), Department of Justice (DOJ) response, or Government Findings report prior to the employee starting work. The facility's own policy requires that background checks be conducted and prohibits the employment of individuals with findings of abuse, neglect, exploitation, or misappropriation. During the survey, it was discovered that several personnel files were missing required documentation, and a facility-wide review was underway to identify which files were incomplete. However, as of the time of the survey, no missing documentation had been updated, and no list of affected employees was provided to the surveyor. The deficiency was identified through record review and staff interviews, confirming that the required background checks were not completed before the registered nurse began employment.
Failure to Complete Comprehensive Assessment After Catheter Removal
Penalty
Summary
The facility failed to provide care and treatment consistent with professional standards of practice for one resident who was re-admitted following a hospitalization and removal of an indwelling catheter. After the resident returned to the facility without the catheter, there was no documentation of comprehensive assessments or monitoring of the resident's ability to void or for potential complications, as required by the nursing process outlined in the Wisconsin Nurse Practice Act. Specifically, there was a lack of documentation from the day after re-admission through the following day, and the Director of Nursing acknowledged that the resident was not assessed or monitored appropriately after re-admission. Interviews with facility leadership revealed that there was no current policy on comprehensive assessments and nurse documentation at the time of the incident. The Director of Nursing and Regional Clinical staff reported that the facility had previously identified concerns with nursing assessments and documentation during a recent re-certification survey and were in the process of developing new policies, procedures, and documentation tools, but these were not yet implemented at the time of the deficiency.
Failure to Provide Required Infection Control Training to Housekeeping Staff
Penalty
Summary
The facility failed to ensure that required infection control training was completed for two housekeeping staff members. Both staff, identified as HSK E and HSK D, reported during interviews that they had not received any infection control training since their respective hire dates. This lack of training was confirmed through record review and staff interviews, indicating that the facility did not have a policy in place for infection control training for housekeeping staff. The Nursing Home Administrator acknowledged that there was no existing policy or documentation of infection control training for these staff members and confirmed that the required training had not been provided. The absence of infection control training for housekeeping staff has the potential to affect all 33 residents in the facility, as these staff perform duties that could impact infection prevention and control.
Failure to Timely Return Resident Trust Funds After Discharge or Death
Penalty
Summary
The facility failed to return funds from resident trust accounts to the residents or their representatives within 30 days after discharge or death, as required. Record review showed that three residents who were either discharged or had expired still had open accounts with remaining balances. Specifically, one resident with diabetes mellitus and multiple sclerosis was found deceased, yet their account remained open with a balance of $0.40. Another resident with hemiplegia following a cerebrovascular accident was discharged, but their account still showed a balance of $100.07. A third resident with heart failure was found unresponsive and deceased, and their account also remained open with a balance of $0.81. Interviews confirmed that the Nursing Home Administrator was aware of the open accounts and the unreturned funds, and acknowledged the lack of a policy for returning funds within the required timeframe. The Business Office Manager, who may have had further information, was unavailable due to being on FMLA. The failure to return funds in a timely manner was identified through both record review and staff interview, affecting three out of four residents reviewed for money due after discharge or death.
Failure to Assess, Document, and Obtain Consent for Wander Guard Use
Penalty
Summary
The facility failed to properly assess and document the need for a Wander Guard alarm for a resident with chronic obstructive pulmonary disease and severe cognitive impairment. The resident was admitted with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, but the most recent elopement risk evaluation documented the resident as not at risk for elopement. Despite this, the care plan identified the resident as an elopement risk and included the use of a Wander Guard device. The device was observed attached to the resident's left ankle, and staff confirmed its use. Interviews with facility staff revealed that there was no written consent or physician's order for the use of the Wander Guard, and no updated elopement risk assessment had been completed to justify its use. The Social Service Director had obtained only verbal consent from the resident's power of attorney after discussing the resident's behavior, but no written documentation of consent was present. The Interim Director of Nursing confirmed the absence of both a physician's order and written consent, as well as the lack of an updated risk assessment supporting the intervention.
Failure to Update Care Plan for Resident's Refusal of Pressure Ulcer Treatment
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan to include a resident's repeated refusals of pressure ulcer treatments and management. The care plan did not document the resident's refusals to have dressing changes performed, wound vac dressings assessed, or wet to dry dressings applied, despite multiple instances of such refusals being recorded in the nursing notes. The facility's policy required that the care plan describe services not provided due to the resident exercising their right to refuse treatment, but this was not reflected in the resident's care plan. The resident involved was cognitively intact, with a history of type two diabetes mellitus and an unstageable pressure ulcer of the sacral region. Nursing notes documented several occasions where the resident refused wound care, dressing changes, and interventions related to the wound vac, as well as non-compliance with turning and repositioning protocols. Despite these documented refusals and non-compliance, the care plan was not updated to reflect the resident's choices or the facility's response to these refusals.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Infection Control Failures During Wound Care and Catheter Management
Penalty
Summary
The facility failed to follow infection control practices during a dressing change for one resident with stage four pressure injuries to both heels. During the dressing change, an LPN placed the resident's wrapped heels on a clean barrier on the bed, then removed the dressings and placed the heels back on the same area of the barrier where the soiled dressings had been. The LPN also brought the treatment cart into the resident's room, contrary to facility expectations. The LPN later acknowledged not keeping clean and dirty areas separate on the barrier and admitted to making mistakes due to nervousness. The Interim Infection Preventionist confirmed that the nurse is expected to keep clean and dirty areas separate and not bring the wound cart into the resident's room. Additionally, the facility failed to maintain proper infection control for a resident with a suprapubic catheter. Observations showed the resident's catheter drainage bag was hanging on the side of the bed and touching the floor on two occasions. Both a CNA and an LPN confirmed that the drainage bag should not touch the floor, and the Interim Director of Nursing also acknowledged this expectation. Review of the facility's urinary catheter policy indicated that catheter tubing and drainage bags must be kept off the floor.
Failure to Complete Admission Skin Assessment for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to complete a comprehensive skin assessment upon admission for a female resident with multiple diagnoses, including diabetes mellitus type 2, severe obesity, and a stage 2 sacral pressure ulcer. The resident was admitted from the hospital with a documented stage 2 pressure injury, but the hospital discharge information did not include wound measurements. Upon admission, only a basic skin assessment was performed by an LPN, which noted bruising on the forearms but did not identify the sacral wound. A comprehensive skin assessment was not completed until two days after admission, at which point an RN documented the stage 2 sacral wound and its measurements. Due to the lack of an initial comprehensive assessment, there was no documentation to determine whether the pressure injury had worsened or improved since admission. The DON confirmed that a comprehensive skin assessment should have been completed upon admission, but this was not done, resulting in incomplete documentation and monitoring of the resident's pressure injury.
Failure to Supervise Resident During Meal
Penalty
Summary
The facility failed to provide the necessary supervision to prevent accidents for a resident, identified as R5, who required close supervision while eating due to aspiration precautions. On the morning of July 31, 2024, a surveyor observed R5 eating breakfast alone in his room without any staff present, despite his care plan and speech therapy recommendations indicating he needed supervision. R5's care plan, updated earlier in the month, specified that he should not be left alone with food and required assistance with eating. However, a Licensed Practical Nurse (LPN) left R5 unattended after administering medication, assuming a Certified Nursing Assistant (CNA) would arrive shortly to assist. The CNA, upon entering the room, expressed surprise that R5 had been given his plate without supervision, acknowledging that R5 was supposed to be monitored while eating. The CNA attributed the oversight to possible miscommunication or lack of awareness by the part-time LPN. Interviews with the LPN, Medical Director, and Speech Language Pathologist confirmed the requirement for supervision and the potential risk of choking if not adhered to. The incident highlighted a lapse in communication and adherence to care protocols, resulting in R5 being left unsupervised during a meal, contrary to his documented care needs.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to accurately assess and manage the pain of a resident, identified as R22, who was reviewed for pain management. The facility's policy requires pain assessments upon admission, quarterly reviews, significant changes in condition, and onset of new or worsening pain. However, R22's pain assessments were inconsistent and did not accurately reflect the resident's pain experience. For instance, R22's pain was documented as sharp and stabbing in the groin prior to hospitalization, but subsequent assessments failed to consistently identify the location and intensity of pain, which varied from 2/10 to 8/10. Additionally, the care plan was not individualized, as it only mentioned migraines and did not address other pain areas such as the back and legs. R22's physician orders included PRN Tylenol #3 and Extra Strength Tylenol, but no non-pharmacological interventions were ordered, and there were no scheduled pain medications. The Medication Administration Record (MAR) showed that R22 experienced moderate to severe pain on numerous days, yet the care plan did not reflect these findings. During interviews, R22 reported significant pain in his legs and back, which limited his mobility and ability to get out of bed. Despite these complaints, the facility did not reassess or adjust the pain management plan to address the resident's needs adequately. Interviews with staff, including a CNA and an LPN, revealed that R22's pain was not consistently managed, and there was a lack of communication regarding the resident's pain levels and management strategies. The LPN acknowledged that R22 had pain most days and attempted to get a scheduled pain medication order, but the physician did not approve it. The Director of Nursing (DON) admitted that the assessments did not indicate the location of R22's pain and recognized the need for changes. The failure to conduct comprehensive pain assessments and provide individualized care resulted in unmet pain management needs for R22.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a Kennedy terminal ulcer, which was in-house acquired and staged by hospice. The deficiency was identified when a surveyor observed a Certified Nursing Assistant (CNA) performing personal care for the resident without donning a gown, despite the presence of a yellow sign on the resident's door indicating that EBP was required. The CNA acknowledged the mistake, attributing it to a misunderstanding during the morning report, where she believed she was informed that EBP precautions were no longer necessary. The Director of Nursing (DON) confirmed that the EBP had been reinstated over the weekend after the resident's wound reopened, but this information was not communicated to the nursing staff on Monday. The facility's procedure for EBP involves the DON or Assistant Director of Nursing (ADON) determining the need for precautions, placing signage, and informing the floor nurse, who is then expected to relay the information to other nursing staff. The lack of proper communication led to the CNA not following the required EBP, resulting in the deficiency.
Failure to Establish Governing Body and Financial Mismanagement
Penalty
Summary
The facility failed to establish a governing body responsible for implementing policies regarding management and operation, leading to significant financial arrears that directly affect resident care. The facility owes substantial amounts to various service providers, including pharmaceutical services, staffing agencies, and electronic healthcare software providers. These overdue balances have resulted in some vendors ceasing their services, which could impact the quality of care provided to the 25 residents in the facility. The Nursing Home Administrator (NHA) indicated that financial concerns are not regularly discussed in meetings with the governing body, and the NHA has limited control over financial matters, which are managed by an external service center and the owner. Interviews with various representatives from service providers confirmed the outstanding balances and the cessation of services due to nonpayment. For instance, Pharm America, which provides medications for residents, has not received payment in 122 days and is considering switching to a cash-in-advance model. Other vendors, such as staffing agencies and suppliers of personal and medical supplies, have also stopped providing services due to unpaid invoices. The facility's financial issues are further compounded by overdue rent payments and bed taxes owed to the state. The owner admitted to hiring and subsequently terminating a financial management company, Future Care Consultants, which disrupted the facility's cash flow. The owner claimed that all vendors have been paid, but surveyors found evidence to the contrary. The NHA and the owner both acknowledged that financial concerns are not adequately addressed in Quality Assurance Program Improvement meetings, and the facility is currently transitioning to a new financial management service, Wipfli, to handle accounts payable and receivable.
Latest citations in Wisconsin
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
