Autumn Lake Healthcare At Greenfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukee, Wisconsin.
- Location
- 5790 S 27th St, Milwaukee, Wisconsin 53221
- CMS Provider Number
- 525504
- Inspections on file
- 34
- Latest survey
- December 13, 2025
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Greenfield during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of inappropriate sexual behavior was not effectively monitored or separated from another severely cognitively impaired resident, resulting in repeated incidents of sexual abuse. Staff failed to report prior incidents to administration, care plans were not updated in a timely manner, and not all caregivers were informed of the need for increased supervision or separation, leading to further abuse.
Two residents with cognitive impairments were involved in incidents of inappropriate touching, which were reported by a family member to staff but not escalated to facility leadership or the state agency as required. The facility did not investigate or implement interventions, and the required abuse reporting protocol was not followed.
A resident with COPD was found to have a nebulizer mask left uncovered on the bedside table when not in use, contrary to facility policy requiring respiratory equipment to be stored in a plastic bag. Both an LPN and the DON confirmed the mask should have been covered, and observations on multiple occasions documented the deficiency.
A resident with a documented fish allergy was served a meal containing fish, despite the allergy being noted in the medical record and on the tray card. The resident did not eat the fish but experienced itching and required medication for relief. Staff interviews confirmed the error and indicated that food allergies were not sufficiently highlighted to prevent such incidents.
A resident with prostate cancer and a femur fracture did not have complete documentation in the medical record regarding the administration of a prescribed cancer medication. An LPN marked the MAR to reference additional details in the Progress Notes but did not document the administration in the notes, despite later recalling that the medication was given after being located with the help of a family member. The DON confirmed that proper documentation was required according to facility policy.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
A resident with intact cognition reported missing money from her purse, and although the Social Services Director assisted in searching and taking statements, law enforcement was not notified as required by facility policy. The Nursing Home Administrator confirmed that such incidents should be reported to police, but this did not occur in this case.
A resident with a history of depression and anxiety reported mistreatment by a CNA, including refusal of care and interference with the resident's ability to call for help. Although the incident was reported to an LPN and care was reassigned, the LPN did not notify facility leadership until the end of the shift, allowing the CNA to continue working in resident care. This delay in reporting and investigation was not in accordance with facility policy and resulted in a failure to immediately protect the resident.
A resident with mental health diagnoses had a care plan intervention to limit new staff assignments, but this was not communicated to CNA staff through care cards or other means. As a result, CNAs were unaware of the intervention and selected their own assignments, leading to an incident where the resident's psychosocial needs were not met during care by unfamiliar staff.
A resident with significant medical conditions was admitted with a Stage 3 sacral pressure injury, but did not receive a comprehensive wound assessment or timely treatment for several days. Wound care orders were inconsistently documented and not always implemented, and weekly wound assessments contained staging errors. Staff failed to consistently follow the care plan for pressure injury prevention, including not offloading the resident's heels or applying pressure-relieving boots, and improper dressing application was observed.
Two residents experienced falls due to inadequate supervision and failure to implement required assistive devices and interventions. In both cases, staff did not thoroughly investigate the circumstances of the falls, failed to follow or communicate care plan requirements such as the use of gait belts, and did not ensure that individualized fall prevention measures were in place or documented. The facility's policies for fall risk management and investigation were not consistently followed.
A resident with diabetes and other medical conditions did not have consistent documentation of meal intake during their stay, despite requiring sliding scale insulin administration based on food consumption. The facility was unable to provide records for most meals, and the nursing home administrator confirmed that staff are expected to document all meal intakes but could not explain the missing documentation.
A resident with type 1 diabetes did not receive ordered sliding scale insulin or blood glucose checks at dinner and bedtime due to delays in transcribing and confirming insulin orders, as staff awaited pharmacy clarification and substitution of insulin types. This resulted in missed administration of both insulin and required monitoring.
A resident with multiple medical conditions experienced a delay in obtaining and processing a urine specimen for a UA and C&S after the initial sample was not received by the lab, requiring a second collection and resulting in a delayed diagnosis and treatment of a UTI. Facility staff and lab representatives confirmed the absence of documentation regarding the first specimen and the delay in results notification.
Staff did not follow infection control protocols for a resident with pressure injuries requiring enhanced barrier precautions. During high-contact care activities, staff failed to wear gowns and did not perform proper hand hygiene, and there was no EBP signage or PPE cart outside the room as required. Interviews revealed confusion about responsibilities and inconsistent adherence to infection prevention policies.
The facility did not ensure daily posting of nurse staffing data, including the date, census, and actual hours worked by RNs, LPNs, and CNAs, in a visible location. Staffing information was not updated or displayed on weekends, as the receptionist responsible for this task was only present on weekdays. This resulted in inaccurate and incomplete postings for three months, affecting access to staffing information for all residents, staff, and visitors.
The facility failed to adhere to professional standards for food storage and ice machine maintenance. Observations revealed improperly stored food items in the freezer and refrigerator, including opened and undated packages. The dry storage area contained unlabeled containers, and the ice machine was covered with a white substance and dust, indicating neglect in maintenance. The Dietary Manager and Maintenance staff were unaware of the cleaning schedule for the ice machine filter, which should be cleaned twice a month.
The facility failed to maintain up-to-date background checks for a CNA, MT, and Cook, as required by their abuse policy. The CNA and MT, who worked directly with residents, had outdated checks, posing a potential risk to resident safety. The lapse was attributed to the absence of a permanent HR employee since September.
A facility failed to accurately document a resident's CPR preference in their EMR, leading to a discrepancy between the signed CPR Preference form and the EMR. The resident's form indicated no CPR, but the EMR showed Full Code. Staff interviews revealed reliance on the EMR for code status, which was incorrect for this resident. The issue was acknowledged by the DON and corrected before the survey ended.
The facility failed to complete Quarterly MDS assessments on time for two residents. The assessments were signed as complete before all sections were finalized, indicating a lack of adherence to the required timeframe. Interviews revealed that the MDS RN worked remotely and signed off prematurely, while the MDS LPN was new to the process. The assessments were admitted to be late, with no further explanation provided.
Two residents' Quarterly MDS assessments were not transmitted to CMS within the required 7-day period after completion. The assessments, completed by an RN working remotely, were submitted late due to oversight. An LPN, new to the MDS process, confirmed the delay during a surveyor's review.
A resident with schizoaffective disorder was not accurately screened for mental disorders in the PASSAR Level I process, leading to the omission of a necessary Level II screening. The Admission Director acknowledged the error, noting that schizophrenia should have been listed, which would have triggered further evaluation. The oversight was identified during a survey, and the Nursing Home Administrator and DON were informed.
The facility failed to develop comprehensive care plans for two residents, one with a foley catheter and another with COPD receiving oxygen and diuretic therapy. The catheter care plan was not implemented upon the resident's return from the hospital, and the other resident's care plan did not address their oxygen and diuretic therapies. The DON acknowledged these oversights.
A resident with Multiple Sclerosis and limited range of motion did not receive the prescribed passive range of motion (PROM) exercises twice daily, as facility staff failed to implement the program. Despite being discharged from active therapy, the resident's care plan required PROM to prevent further contractures. Interviews revealed that staff were not adequately trained or informed about the program, leading to inconsistent care and the resident's decline.
A resident at the facility, assessed as a high fall risk, did not have an adequate care plan developed or updated following a fall. Despite the facility's policy requiring comprehensive care plans, the resident's plan was not initiated or revised in a timely manner to include necessary fall prevention interventions. The Director of Nursing could not explain the oversight, and the care plan was only updated after surveyor intervention.
A hospice resident with severe pain was not administered scheduled Morphine as ordered, due to staff holding the medication when the resident was sleeping, despite no physician instructions to do so. The facility's lack of documentation and communication among staff led to the resident not receiving appropriate pain management, contrary to the care plan and professional standards.
A resident with multiple diagnoses, including dementia and diabetes, did not have a medication dose adjustment acted upon by the facility. A Consultant Pharmacist recommended reducing the dose of pantoprazole, which was signed by a Nurse Practitioner, but the order was not updated in the electronic medical record. The interim Assistant DON was responsible for updating orders but did not make the necessary change.
A facility failed to attempt a gradual dose reduction (GDR) for a resident on olanzapine, prescribed for sundowning with dementia. Despite a pharmacy recommendation for a GDR, an unknown NP indicated it was unnecessary due to a psychiatric disorder, which was not supported by the resident's medical record. The resident exhibited no significant behaviors in November 2024, and a psychiatric NP noted normal mood and affect. The NHA was unaware of the NP's identity and acknowledged the need to investigate the lack of a GDR attempt.
Two residents in an LTC facility received inadequate pressure ulcer care. One resident's Stage 3 pressure injury was not comprehensively assessed upon admission, with inconsistent documentation of skin condition. Another resident, with a history of pressure injuries, was observed without required heel boots, contrary to their care plan. Staff interviews revealed unclear roles and inadequate documentation practices, contributing to the deficiencies.
A resident with multiple health issues and a moderate fall risk was observed to have only one fall mat in their room, despite their care plan requiring two. The care plan had not been updated since its initiation, and the discrepancy was confirmed by an LPN who was unfamiliar with the electronic charting system. The issue was reported to the DON, but no further action was noted.
A resident readmitted with a Foley catheter did not have physician orders for its care, leading to a deficiency in treatment. The facility's process for obtaining and implementing readmission orders was inadequate, as the hospital discharge summary lacked specific catheter care instructions. Staff interviews revealed reliance on incomplete documentation and a lack of clear communication regarding the resident's care needs.
A resident with a history of pressure injuries developed three new Stage 3 pressure injuries due to the facility's failure to revise the care plan with specific interventions for repositioning and incontinence care. The resident, who required substantial assistance and was at risk for pressure injuries, was often left in the same position for extended periods. Additionally, there were lapses in communication and documentation regarding the resident's condition, contributing to inadequate pressure ulcer care.
A resident with a significant decline in condition was readmitted to a facility without an updated care plan or CNA Kardex, leading to inadequate supervision and a fall resulting in injury. Despite requiring maximal assistance with ADLs and being at moderate risk for falls, the facility failed to revise care plans based on hospital recommendations, highlighting a lack of communication and documentation among staff.
A resident with severe cognitive impairment was observed self-administering Medihoney for wound care without an assessment by the interdisciplinary team. The facility's policy requires such an assessment to ensure safety, but no documentation was found in the resident's medical record. The RN/UM confirmed that the resident had not been taught to self-administer treatments, as she was not supposed to do so.
The facility failed to resolve grievances for two residents, including a missing CPAP machine and care concerns. Despite multiple notifications, grievances were not documented or investigated, violating the facility's policy and residents' rights.
The facility failed to thoroughly investigate allegations of abuse and protect residents during investigations. In one case, a resident-to-resident altercation was not fully investigated as other residents were not interviewed. In another case, a CNA accused of verbal abuse was allowed to continue working with residents during the investigation, contrary to facility policy. The facility's policies on abuse prevention and investigation were not fully adhered to, contributing to the deficiency.
The facility failed to provide care according to professional standards and resident care plans. A resident with severe cognitive impairment was found self-administering wound care due to delays, contrary to physician orders. Another resident was given a wander guard without a proper assessment and lacked a smoking assessment despite being identified as a smoker. These actions indicate non-compliance with facility policies for resident safety and care.
A resident with dementia was prescribed Donepezil and Olanzapine for behavior management, but the facility failed to document behavior monitoring as required. Despite the care plan's directive for monitoring, the Director of Nursing confirmed that this was not done since the resident's admission, raising concerns about the medication regimen's appropriateness.
A facility failed to maintain an effective infection prevention and control program, as staff did not adhere to enhanced barrier precautions (EBP) for a resident with Stage 3 pressure injuries. Observations revealed the absence of EBP signage and PPE carts, and staff did not wear gowns or perform proper hand hygiene during incontinence care. Interviews with facility staff indicated a lack of awareness and communication regarding EBP requirements.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Reporting and Care Planning
Penalty
Summary
The facility failed to protect a cognitively impaired resident from sexual abuse by another resident with a history of inappropriate sexual behavior. One resident, who had diagnoses of metabolic encephalopathy and dementia and was moderately cognitively impaired, had previously attempted to kiss another resident and was reported to have tried to fondle the breasts of a severely cognitively impaired resident. Despite these incidents, the facility did not implement effective preventive measures or update the resident's care plan to address these behaviors until after a subsequent incident occurred. On a later occasion, staff witnessed the same resident with his hand down the pants of the cognitively impaired resident in a common area. Although staff immediately intervened and separated the residents, prior reports of inappropriate behavior had not been communicated to administration or properly documented. Interviews revealed that some staff were aware of previous incidents but did not report them to administration or initiate an investigation, and other staff were unaware of the need to monitor or separate the residents. The care plan for the resident exhibiting inappropriate behavior was not updated to include interventions for these behaviors until after the most recent incident. The facility's failure to report, investigate, and implement preventive measures following initial incidents allowed further abuse to occur. There was a lack of communication among staff and administration regarding the resident's behaviors, and no safety risk evaluation was completed prior to the most recent incident. The facility did not revise the care plan for the victimized resident after the incidents, and not all caregivers were informed of the need for increased monitoring or separation of the residents involved.
Removal Plan
- Completed a root cause analysis to identify failure to report abuse to administration and prevent reoccurrence.
- Assessed each resident and established a care plan and supervision.
- Established systems to monitor and document frequency of behaviors.
- Completed assessments as indicated by psych services.
- Trained facility staff on practices and changes to systems.
- Established a system for auditing and monitoring along with QAPI.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the state agency, as required by policy. One resident with dementia and moderate cognitive impairment was documented in a psychiatric progress note for inappropriately attempting to kiss another resident, and staff were instructed to redirect him and keep him away from vulnerable patients. However, there was no care plan addressing sexual inappropriateness for this resident prior to a later date. Another resident, who was severely cognitively impaired and dependent on staff for mobility, was reported by a family member to have been touched inappropriately by the first resident. This information was relayed to a unit manager and a certified medication aide, but neither the social worker, DON, ADON, nor the administrator were made aware of the allegations or the incident documented in the psychiatric note. As a result, the facility did not investigate the incidents or implement interventions to prevent further occurrences. The lack of reporting and investigation allowed the inappropriate behavior to continue, as there was no documentation of actions taken to address the situation. The facility's policy required immediate reporting of all alleged violations to the administrator, state agency, and other authorities, but this protocol was not followed in these cases.
Failure to Maintain Cleanliness of Nebulizer Mask
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease (COPD) was observed to have a nebulizer mask left uncovered on the bedside table when not in use. The resident had a physician's order for Budesonide Inhalation Suspension to be administered twice daily for shortness of breath related to COPD. Observations on two separate occasions confirmed that the nebulizer mask was not stored in a plastic bag as required by facility policy. Interviews with an LPN and the Director of Nursing confirmed that the nebulizer mask should have been kept in a plastic bag when not in use, in accordance with the facility's policy on oxygen administration. The failure to properly store the nebulizer mask represented a lapse in maintaining the cleanliness of respiratory equipment for the resident.
Failure to Prevent Allergen Exposure in Resident Meal Service
Penalty
Summary
A deficiency occurred when a resident with a documented fish allergy was served a meal containing fish. The resident's electronic medical record included clear documentation of the fish allergy, and the allergy was also noted on the resident's tray card. Despite these precautions, the resident received a tray with fish during supper. The resident did not consume the fish but reported experiencing itching after having the fish in her room, which led to the administration of Benadryl and hydrocortisone ointment for relief. The resident was cognitively intact and communicated her allergy and reaction to staff. Interviews with staff revealed that the dietary aide responsible for serving the meal was made aware of the error and was sent home early that day. The Dietary Manager stated that staff were instructed to highlight food allergies to prevent similar incidents. The facility's policy on menus and nutrition required documentation of resident preferences but did not specifically address food allergies. The administrator confirmed the expectation that dietary staff should be attentive to resident allergies and avoid serving allergenic foods.
Incomplete Documentation of Medication Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident. The resident, who was admitted with a left femur fracture and prostate cancer with bone metastasis, had a physician's order for apalutamide, a hormone blocker used to treat prostate cancer. On a specific date, the Medication Administration Record (MAR) indicated with code 9 that additional details regarding the administration of apalutamide should be referenced in the Progress Notes. However, a review of the Nursing Progress Notes revealed there was no documentation about the administration of the medication on that date. During an interview, an LPN recalled being unable to initially locate the cancer medication, but after a family member identified its location in the medication cart, the LPN administered it to the resident. The LPN was unsure if she documented the administration in the nurses' notes, despite having marked code 9 on the MAR. The Director of Nursing confirmed that the nurse should have either documented the medication as given or provided an explanation in the nurses' notes. The facility's policy requires documentation of medication administration or refusal as per facility guidelines.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident grievances in a timely and non-discriminatory manner.
Failure to Timely Report Alleged Misappropriation to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's money to local law enforcement within the required timeframe. The incident involved a resident with diagnoses including major depressive disorder, anxiety disorder, transient cerebral ischemic attack, and a history of repeated falls, who was cognitively intact at the time of the event. The resident reported missing money from an envelope in her purse and stated that the Social Services Director (SSD) took statements and assisted in searching for the missing money, but the money was not found and law enforcement was not contacted. Interviews revealed that the SSD did not notify the police because the resident expressed a desire to call the police herself and did not want the SSD to do so. The Nursing Home Administrator (NHA) confirmed that the expectation for such allegations was to contact law enforcement, but was on vacation during the incident. The facility's policy requires reporting all alleged violations, including misappropriation, to the administrator, state agency, Adult Protective Services, and law enforcement when applicable. Despite this, the required notification to law enforcement was not made for this incident.
Failure to Immediately Report and Investigate Alleged Mistreatment
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate and respond appropriately to an allegation of mistreatment involving a resident. The resident, who had diagnoses including major depressive disorder, anxiety disorder, and a history of transient cerebral ischemic attack, reported an incident involving a Certified Nursing Assistant (CNA) during morning care. The resident, who was cognitively intact, alleged that after requesting to use the toilet, the CNA used vulgar language, refused the request, and unplugged the resident's phone when the resident attempted to call the office. The resident then called out for help until another CNA responded and provided care for the remainder of the shift. The facility's policy requires immediate investigation and protection of residents when allegations of abuse, neglect, or exploitation arise. However, after the incident, the CNA in question continued to work in resident care for the rest of the shift. The nurse on duty was informed of the allegation and reassigned the resident's care to another CNA, but did not report the incident to the Nursing Home Administrator (NHA) or Social Services Director (SSD) until the end of the shift. This delay in reporting resulted in the alleged staff member remaining in a position to provide resident care after the allegation was made. Interviews with staff confirmed that the incident was not reported to facility leadership in a timely manner, contrary to facility policy. The NHA and SSD both indicated that they were only made aware of the situation at the end of the shift, and the CNA was suspended only after leadership was informed. The investigation documentation and staff interviews corroborated that the required immediate response and reporting procedures were not followed, leading to a lapse in resident protection during the investigation period.
Failure to Implement Person-Centered Care Plan for Resident's Psychosocial Needs
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive, person-centered care plan to address a resident's mental and psychosocial needs as identified in their assessment. The resident, who had diagnoses including major depressive disorder, anxiety disorder, and a history of falls, had an intervention documented in their behavioral care plan to limit the assignment of new staff or to have established staff introduce new staff slowly. This intervention was intended to help set a positive tone and build trust with the resident. Despite being documented in the nurse's care plan, this intervention was not included on the CNA care plan or care card, which are the primary tools used by CNA staff to guide daily care. Multiple interviews with CNA staff revealed that they were unaware of the intervention, as it was not communicated to them through the care cards or posted in the resident's room. Staff also reported that CNAs typically select their own resident assignments and that there was no system in place to ensure that new or agency staff were limited in their assignment to this resident, as required by the care plan. The deficiency was further evidenced by an incident in which the resident experienced distress during care provided by a CNA unfamiliar to them, resulting in a negative interaction. The lack of communication and implementation of the care plan intervention meant that staff were not informed of the resident's specific needs, leading to the failure to provide care consistent with the resident's assessed mental and psychosocial requirements.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
A resident with multiple comorbidities, including sickle cell disease, chronic kidney disease, cerebral infarction, hypertension, diabetes mellitus, and spastic hemiplegia, was admitted to the facility with a Stage 3 sacral pressure injury. Upon admission, there was no comprehensive wound assessment or treatment initiated until four days later. Initial physician orders for wound care were either not started, not documented as completed, or not transferred onto the treatment administration record (TAR), resulting in a delay in necessary wound care interventions. Throughout the resident's stay, weekly wound assessments were not consistently accurate, with pressure injuries on the right and left buttocks being incorrectly staged as Stage 2 when documentation described granulation tissue, which is not present in Stage 2 wounds. Observations during the survey revealed that staff did not consistently follow the care plan interventions, such as applying bilateral heel boots or offloading the resident's heels. The resident was frequently observed in bed without pressure-relieving boots, and her heels were resting directly on the mattress or on pillows without being properly offloaded, contrary to the care plan and professional standards of practice. Additionally, wound care was not always performed according to best practices. During a treatment observation, the adhesive portion of a border gauze dressing was applied directly over an open pressure injury, which was later confirmed by the wound physician as inappropriate. Staff interviews indicated a lack of clarity regarding wound assessment, staging, and dressing selection. The facility did not provide an explanation for the delay in comprehensive assessment and treatment initiation, nor for the incorrect staging of wounds and failure to consistently offload the resident's heels as required.
Failure to Prevent Accidents Due to Inadequate Supervision and Implementation of Fall Interventions
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistive devices to prevent accidents, as evidenced by incidents involving two residents. In the first case, a resident with diagnoses including Guillain-Barre syndrome, anxiety disorder, hypertension, and morbid obesity, and assessed as having moderate cognitive impairment and being dependent for transfers and toileting, experienced a fall. The facility did not thoroughly investigate the circumstances of the fall, including whether prior fall interventions were in place. Staff statements did not clarify when the resident was last checked, changed, or offered the commode, despite the resident stating she fell while attempting to use the bathroom. Additionally, a CNA was observed transferring the resident without a gait belt, contrary to the resident's care plan, and was unaware that a gait belt was required for transfers. The CNA relied on a roster that did not specify the need for a gait belt, and the DON confirmed that staff are expected to use gait belts but could not confirm consistent practice or staff awareness of individual resident requirements. In the second case, another resident with multiple diagnoses, including sickle cell disease, chronic kidney disease, cerebral infarction, and spastic hemiplegia, fell while reaching for something from her wheelchair. The baseline care plan identified the resident as at risk for falls but did not include any specific interventions or approaches. The facility's investigation into the fall was incomplete, as the staff statement obtained was from a CNA not scheduled to work at the time of the incident, and there was no evidence that the CNAs who were present were interviewed. The care plan addressing fall risk was not developed until after the fall occurred, and the investigation did not clarify the circumstances leading up to the fall or whether appropriate interventions were in place at the time. Both incidents demonstrate a lack of thorough investigation and failure to ensure that care plans and interventions were communicated and implemented as required. Staff were either unaware of or did not follow the prescribed interventions, such as the use of gait belts during transfers, and documentation was insufficient to determine whether residents were adequately supervised or assisted to prevent accidents. The facility's policies required individualized interventions and thorough investigations, but these were not consistently followed in the cases reviewed.
Failure to Document Meal Intake for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident with multiple medical conditions, including type 1 diabetes, right femur fracture, Parkinson's disease, and anxiety, maintained acceptable parameters of nutritional status. The resident was admitted and subsequently discharged to the hospital due to a change in condition. During the resident's stay, the facility did not consistently document meal intake, which was necessary for monitoring nutritional status and for the safe administration of sliding scale insulin as ordered by the physician. The only available documentation showed that the resident ate 75%-100% of one meal, with no records for subsequent meals during the remainder of the stay. Despite the resident requiring supervision for activities of daily living and being cognitively intact, there was no evidence in the electronic medical record of meal intake for most of the resident's stay. The facility's nursing home administrator confirmed that staff are expected to document all meal intakes but was unable to provide additional documentation or explain the lack of records. This lack of documentation meant the facility could not demonstrate that the resident's nutritional needs were being met or that insulin was administered safely in accordance with the resident's meal consumption.
Failure to Administer Ordered Insulin and Blood Glucose Checks Due to Delayed Order Transcription
Penalty
Summary
A resident with diagnoses including type 1 diabetes, right femur fracture, Parkinson's disease, and anxiety was admitted to the facility with physician orders for sliding scale Novolog insulin at all meals and bedtime, blood glucose checks at all meals and bedtime, and Lantus 30 units at bedtime. On the day of admission, the medication administration record (MAR) shows that the resident did not have a blood glucose check completed for the dinner meal and did not receive any insulin at that meal. At bedtime, although the blood glucose was checked and Lantus was administered, the ordered sliding scale Novolog insulin was not given, despite the MAR indicating it was required. Interviews with nursing staff revealed that the sliding scale insulin and blood glucose check orders were not transcribed into the MAR until later, with the Novolog sliding scale order entered in the evening and the blood glucose check order the following day. Staff indicated that there was a delay in confirming the insulin orders due to the pharmacy needing to substitute Humalog for Novolog, as only Humalog was available. This delay in order transcription and confirmation resulted in the resident not receiving the prescribed insulin and blood glucose monitoring as ordered on the day of admission.
Delay in Laboratory Testing and Notification for UTI
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a laboratory test was obtained and processed in a timely manner for one resident. The resident, who had diagnoses including acute cerebrovascular insufficiency, anxiety, depression, and alcohol use, was cognitively intact and required supervision for toileting. An order for a urinalysis (UA) and culture and sensitivity (C&S) was placed, and the urine specimen was initially collected as ordered. However, there was no documentation regarding what happened to the first specimen collected, and the laboratory did not receive it. As a result, a second urine sample had to be collected two days later, and the laboratory did not receive this specimen until the following day. The delay in obtaining and processing the laboratory test led to a delay in identifying a urinary tract infection (UTI) and initiating antibiotic treatment. Nursing notes indicated that the results were pending for several days, and the nurse practitioner was not updated with the results until the laboratory reported them. Interviews with facility staff and the laboratory confirmed that the initial specimen was not received, and there was no clear documentation explaining the delay or the need for a second collection.
Failure to Implement Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program for a resident requiring enhanced barrier precautions (EBP) due to pressure injuries. Multiple observations revealed that staff did not follow established protocols for hand hygiene and use of personal protective equipment (PPE) during high-contact care activities, such as incontinence care and wound treatment. Specifically, staff were observed not wearing gowns as required, and hand hygiene was not performed at appropriate times, such as after glove removal and between care tasks. The resident involved had significant medical conditions, including sickle cell disease, chronic kidney disease, cerebral infarction, hypertension, diabetes mellitus, and spastic hemiplegia, and was documented to have pressure injuries on the sacrum and right buttocks. The care plan and facility policy required EBP, including the use of gowns and gloves for high-contact care, signage on the resident's door, and the availability of PPE at the point of care. However, there was no EBP sign or PPE cart outside the resident's room during multiple observations, and staff were not consistently aware of or adhering to EBP requirements. Interviews with staff and the Director of Nursing confirmed lapses in protocol, including uncertainty about who was responsible for ensuring EBP signage and PPE availability, and acknowledgment of shortages in PPE carts. Staff also demonstrated inconsistent knowledge and practice regarding hand hygiene and PPE use, as evidenced by their actions during observed care episodes. The surveyor was unable to locate a physician order for EBP in the resident's records, further indicating gaps in the implementation of infection control measures.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data, including the date, resident census, and total actual hours worked by RNs, LPNs, and CNAs, was posted daily in a visible and accessible location. The nurse staffing posting was not updated or displayed on weekends, as the responsibility for updating the document fell solely on the receptionist, who only worked Monday through Friday. As a result, the staffing information was not accurately posted or maintained for the three months reviewed, and the postings did not reflect the actual number of staff present in the building on a daily basis. Interviews with the receptionist and the Nursing Home Administrator confirmed that the process for updating the nurse staffing hour document was not followed on weekends, and that new receptionists had not been educated on this responsibility. The surveyor's review of schedules and posted documents for January, February, and March revealed discrepancies and missing updates, affecting the ability of residents, staff, and visitors to access accurate staffing information. This deficiency had the potential to affect all 82 residents residing in the facility.
Deficient Food Storage and Ice Machine Maintenance
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed during a survey. In the kitchen's freezer, an unopened package of imitation crab meat, an opened bag of whipped topping, and three small containers of ice cream were found on the floor, contrary to the facility's policy that requires food to be stored at least six inches from the floor. Additionally, opened boxes of hamburger patties and hot dogs were not sealed or dated, violating the policy that mandates foods in the refrigerator to be covered, labeled, and dated. In the dry storage area, containers with red beans and pearled barley were not labeled or dated, further breaching the facility's storage guidelines. The ice machine outside the freezer door was covered with a dry, crusty white substance, and its filter was heavily dust-covered, indicating neglect in maintenance. The Dietary Manager admitted to not knowing the cleaning schedule for the ice machine filter, which should be cleaned twice a month according to the sign on the machine. The Maintenance staff also confirmed that the facility does not handle the cleaning or changing of the ice machine filter, which is contracted out. These observations were communicated to the Nursing Home Administrator, but no additional information was provided to explain why the facility did not adhere to professional standards for food service safety.
Failure to Maintain Up-to-Date Employee Background Checks
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not ensuring that background checks were up to date for three employees, including a Certified Nursing Assistant (CNA), a Medication Technician (MT), and a Cook. The policy required background checks to be conducted every four years to screen for any history of abuse, neglect, exploitation, or misappropriation of resident property. However, the background checks for these employees had lapsed beyond the four-year requirement. Specifically, the CNA and MT, who worked directly with residents, had their last background checks completed over four years ago, and the Cook, who did not have direct resident contact, also had outdated background check information. The deficiency was identified during a survey when the Nursing Home Administrator (NHA) was unable to provide current background check documentation for these employees. The NHA acknowledged the oversight and indicated that the facility had been without a permanent Human Resources (HR) employee since September, which contributed to the lapse. The NHA had completed the necessary background checks after the surveyor's request, but this action was not timely, as it occurred only after the deficiency was identified. The lack of up-to-date background checks for employees who have direct contact with residents posed a potential risk to resident safety and well-being.
Discrepancy in Resident's CPR Preference Documentation
Penalty
Summary
The facility failed to ensure that a resident's advance directive wishes were accurately reflected in their medical record. A resident, identified as R47, had a signed Cardiopulmonary Resuscitation (CPR) Preference form indicating they did not want CPR attempts. However, the electronic medical record (EMR) for R47 incorrectly documented the resident's code status as Full Code, which contradicted the resident's expressed wishes. This discrepancy was discovered during a surveyor's review of the resident's records. Interviews with facility staff revealed a breakdown in the process of updating and verifying the resident's code status in the EMR. The Licensed Practical Nurse (LPN) indicated that they would rely on the EMR to determine a resident's CPR preference, which would not have provided accurate information for R47. The Social Services Director and Admissions staff confirmed that the CPR Preference form is included in the admission packet and should be uploaded into the EMR. The Director of Nursing acknowledged the discrepancy and indicated that the facility would need to correct the code status in the EMR for R47. The surveyor informed the Nursing Home Administrator of the concern, and the discrepancy was reportedly fixed before the survey concluded.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete Quarterly Minimum Data Set (MDS) assessments in a timely manner for two residents, R71 and R45. For R71, the Quarterly MDS assessment was dated with sections signed as completed on various dates in November 2024, but the assessment was signed in Section Z as being completed on November 12, 2024, which was before any sections were actually completed. Similarly, for R45, the Quarterly MDS assessment was dated with sections signed as completed in early December 2024, yet Section Z was signed as completed on November 13, 2024, prior to the completion of other sections. This discrepancy indicates that the assessments were not completed within the required timeframe, as the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD). Interviews with facility staff revealed that the MDS RN responsible for signing off on the assessments was working remotely and had signed the assessments as complete before the other sections were finalized. The MDS LPN, who had recently started handling MDS assessments, was unable to provide a clear process for scheduling and completing assessments. The MDS RN admitted that the assessments for R71 and R45 were late and had been missed initially, leading to their late completion. The Nursing Home Administrator was informed of the late assessments, but no additional information was provided to explain why the facility failed to ensure timely completion of the Quarterly MDS assessments.
Delayed Transmission of MDS Assessments
Penalty
Summary
The facility failed to transmit the Quarterly Minimum Data Set (MDS) assessments for two residents, R71 and R45, within the required 7-day period after completion. R71's assessment was completed on 11/12/2024, and R45's on 11/13/2024, but both were not submitted to the Centers for Medicare and Medicaid Services (CMS) until 12/10/2024. This delay was identified during a surveyor's review, which noted that the facility's policy required transmission within 14 days of completion, yet the assessments were still late. During an interview, MDS LPN-X, who had recently started handling MDS assessments, indicated that MDS RN-Y, who was responsible for the submissions, was working remotely and had forgotten to transmit the assessments. MDS RN-Y confirmed the oversight in a phone interview, acknowledging the late submission of the assessments. The Nursing Home Administrator was informed of the issue, but no additional information was provided to explain why the facility did not ensure timely transmission of the assessments.
Failure to Accurately Screen Resident for Mental Disorders in PASSAR Process
Penalty
Summary
The facility failed to accurately screen a resident for mental disorders as part of the Preadmission Screening and Resident Review (PASSAR) process. A resident was admitted with diagnoses including opioid dependence, delirium, schizoaffective disorder, heart failure, type 2 diabetes, and major depressive disorder. However, the PASSAR Level I screen completed for this resident did not identify any mental disorders, despite the presence of schizoaffective disorder, which should have triggered a Level II PASSAR. This oversight was attributed to the Business Office Manager who signed off on the Level I screen without noting the mental disorder. During an interview, the Admission Director acknowledged the error, stating that schizophrenia should have been listed as a mental illness on the PASSAR Level I screen, which would have necessitated a Level II screening. The Admission Director admitted to not having completed the initial PASSAR Level I screen for the resident but recognized the need to review and correct it once she assumed responsibility for the facility's PASSARs. The Nursing Home Administrator and Director of Nursing were informed of these findings, but no additional information was provided to the surveyor.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in meeting their medical, nursing, and psychosocial needs. One resident, who was readmitted to the facility with a foley catheter following a hospital stay, did not have a catheter care plan implemented upon their return. Despite having a physician order for a foley catheter due to retention, the care plan was not updated to include this intervention until several weeks later. The Director of Nursing confirmed the absence of an individual care plan for the catheter, acknowledging the oversight. Another resident with Chronic Obstructive Pulmonary Disease (COPD) and receiving oxygen therapy and diuretic medication also lacked a comprehensive care plan addressing these therapies. The resident's physician orders included continuous oxygen therapy and a diuretic for diuresis, yet these were not reflected in the care plan. The Director of Nursing indicated that while they typically do not start a diuretic care plan, they would expect to see one included eventually. The absence of these care plans was noted by the surveyor, highlighting a failure to address the resident's specific medical needs in their care plan.
Failure to Implement Range of Motion Program for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment to prevent further contractures and decreased range of motion in their upper and lower extremities. The resident, who was admitted with diagnoses including Multiple Sclerosis, Hemiparesis, Hemiplegia, Paraplegia, Quadriplegia, and contracture of the left hand, was supposed to receive a passive range of motion (PROM) program twice daily as ordered by the physical therapy department. However, the program was not consistently implemented by the facility staff, leading to the resident's decline in condition. Interviews with the resident and their family revealed that the facility staff did not perform the range of motion exercises as required, and the family had to provide additional support and equipment for the resident's care. The Director of Therapy confirmed that the resident was discharged from active therapy services and was set up with a passive range of motion program to be completed by facility staff. However, the staff did not have clear documentation or training on how to implement the program, and there was no evidence of the exercises being performed consistently. Further interviews with various staff members, including CNAs and the Nursing Home Administrator, highlighted a lack of communication and documentation regarding the resident's restorative program. The staff were unsure of where to find the program details or how to document the exercises, and the restorative aide, who was trained on the exercises, was not provided with the necessary materials to train other staff. As a result, the resident's care plan, which required passive range of motion exercises twice daily, was not followed, contributing to the resident's decline in range of motion and increased contractures.
Failure to Develop and Update Fall Prevention Care Plan
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident identified as R335. Despite being assessed as a moderate risk for falls on one occasion and a high risk following a fall, the facility did not develop or update a comprehensive care plan to address these risks. The resident, who was readmitted to the facility with conditions including cellulitis, type 2 diabetes, and metabolic encephalopathy, experienced a fall on 9/28/2024. However, the care plan was not initiated or updated with interventions to prevent further falls, such as encouraging the resident to call for assistance when transferring and keeping a walker within close reach. The facility's policy requires that a comprehensive care plan be developed and maintained for each resident, incorporating identified problem areas and risk factors. Despite this, the care plan for R335 was not initiated or revised in a timely manner following the fall, and the Director of Nursing was unable to provide an explanation for this oversight. The surveyor noted that the care plan was eventually updated, but this occurred after the surveyor's intervention and was not part of the initial response to the resident's fall.
Failure to Administer Scheduled Pain Medication to Hospice Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a hospice resident, identified as R38, who was not administered his scheduled pain medication as ordered. R38, who was admitted to the facility on hospice care, had a medical history including Diastolic Congestive Heart Failure, Hypertension, Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Myocardial Infarction. The resident's comprehensive assessment indicated frequent and severe pain, which affected his sleep and daily activities. Despite this, the facility did not administer the prescribed Morphine Sulfate Oral Solution every two hours as ordered, with documentation showing that the medication was held on several occasions without a valid reason. The report highlights that the facility's policy on pain management requires adherence to professional standards of practice and the resident's care plan. However, the facility staff failed to follow these guidelines, as evidenced by the Medication Administration Record (MAR) entries that indicated the medication was held because the resident was sleeping. The physician's order did not include instructions to hold the medication if the resident was asleep, yet the nurses assumed that the resident did not require pain management during these times. This assumption led to the resident going without pain medication for extended periods, as reported by the resident's Power of Attorney and confirmed by the hospice nurse. The deficiency was further compounded by the lack of documentation explaining why the medication was not administered and the absence of communication and education among the nursing staff regarding the proper administration of scheduled pain medication. The Director of Nursing acknowledged the issue but had not yet provided comprehensive education to all staff members. This oversight resulted in the resident not receiving the necessary pain management, contrary to the facility's policy and the resident's care plan.
Failure to Act on Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to ensure the accurate and safe administration of medication for a resident, identified as R47, who was admitted with multiple diagnoses including cerebral infarction, dementia, type 2 diabetes mellitus, hemiplegia, hemiparesis following cerebral infarction, and aphasia. The resident's Minimum Data Set indicated moderate cognitive impairment. A Consultant Pharmacist Recommendation to reduce the dose of pantoprazole to 20 mg per day was signed by the Nurse Practitioner but was not acted upon by the facility. As of December 11, 2024, the electronic medical record still reflected an order for Pantoprazole Sodium Oral Tablet Delayed Release 40 MG, indicating no change in the dose had been made. The Director of Nursing (DON) was interviewed and stated that the interim Assistant DON was responsible for updating physician and medication orders in December, but was unsure why the update was not made. The Nursing Home Administrator was informed of the concern that the pharmacy recommendation, which was signed by the Nurse Practitioner, was not acted upon. The discrepancy was reportedly fixed before the surveyor exited the survey, but no additional information was provided regarding the resolution.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) for a resident on antipsychotic medication, specifically olanzapine, which was prescribed for sundowning associated with dementia. The resident, who has a diagnosis of dementia with psychotic disturbance and major depressive disorder, was noted to have severe cognitive impairment but did not exhibit physical or verbal aggression or rejection of care behaviors. Despite a pharmacy recommendation for a GDR attempt, an unknown nurse practitioner (NP) indicated that a GDR was not needed due to a psychiatric disorder, although the resident's medical record did not support the presence of such a diagnosis. The surveyor's findings highlighted that the resident's behaviors, such as delusional beliefs, verbal aggression, and tearfulness, were being monitored, but no behaviors were noted in November 2024. A psychiatric NP note from November 28, 2024, indicated the resident's mood was normal, with no delusions, paranoia, or hallucinations, and that olanzapine was used for dementia with moderate agitation. The Nursing Home Administrator (NHA) was unaware of the NP who signed off on the pharmacy recommendation and acknowledged the need to investigate the lack of a GDR attempt. As of December 12, 2024, no additional information was provided regarding the failure to attempt a GDR for the resident's antipsychotic medication.
Inadequate Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for two residents, R14 and R13, leading to deficiencies in their treatment and prevention of further injuries. R14 was admitted with a Stage 3 pressure injury to the right buttock, which was not comprehensively assessed upon admission. The initial assessment lacked documentation of the tissue type and the number of open areas, and the comprehensive assessment was only completed four days later by a wound physician. Additionally, there were inconsistencies in the documentation of R14's skin condition, with records indicating both intact and non-intact skin on different days without detailed descriptions. R13, who was severely cognitively impaired and receiving hospice care, was observed without heel boots while sitting in a Broda chair, contrary to the care plan that required bilateral heel boots to prevent further pressure injuries. Despite having a history of pressure injuries and a current Stage 4 pressure injury to the sacrum, R13's care plan was not consistently followed, as staff were unaware of the requirement for heel boots. Observations revealed that R13's feet were pressed against the footboard of the chair, increasing the risk of further injury. Interviews with facility staff highlighted a lack of clarity and communication regarding the roles and responsibilities for wound assessments and care. The facility's documentation practices were also found to be inadequate, with important assessment details not being included in the medical record. This lack of comprehensive documentation and adherence to care plans contributed to the deficiencies observed in the care of residents with pressure injuries.
Failure to Provide Adequate Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident, identified as R13, received adequate assistance devices to prevent accidents, specifically regarding the use of fall mats. R13's care plan, initiated on January 28, 2022, included the intervention of bilateral fall mats on the floor to mitigate the risk of falls. However, observations made by a surveyor on September 24, 2024, revealed that R13 had only one fall mat in the room, contrary to the care plan's requirement for two. This discrepancy was noted during two separate observations, one when R13 was in a Broda chair in the common area and another when R13 was lying in bed. R13 was admitted to the facility with multiple diagnoses, including osteoarthritis, malnutrition, anxiety, chronic kidney disease, and Alzheimer's disease, and was receiving hospice services. The resident was assessed as severely cognitively impaired and at moderate risk for falls. Despite these conditions, the care plan had not been revised since its initiation, and no falls had been documented for R13. The issue was brought to the attention of an LPN, who confirmed the care plan's requirement for bilateral fall mats but was unfamiliar with the electronic charting system, causing a delay in verifying the information. The Director of Nursing was also informed of the deficiency, but no further information was provided at that time.
Deficiency in Foley Catheter Care for Readmitted Resident
Penalty
Summary
The facility failed to ensure that a resident with a Foley catheter received appropriate care and treatment, as there were no physician orders for the catheter's care upon the resident's readmission. The resident, who had a history of rhabdomyolysis, stage 3 kidney disease, type 2 diabetes, acute hypoxic respiratory failure, and urinary retention, was readmitted to the facility after a hospital stay. The hospital discharge summary did not include orders for the care and treatment of the newly placed Foley catheter, and the facility's care plan for the resident did not include specific interventions for catheter care. Interviews with facility staff revealed gaps in the process for obtaining and implementing readmission orders. The Unit Manager, who was new to the position, had not fully completed a readmission and relied on the Assistant Director of Nursing or Director of Nursing to handle the process. The CNA Kardex, which staff used to determine care needs, only mentioned providing Foley care every shift without specific instructions. It was only after the surveyor's inquiry that the Unit Manager updated the resident's physician orders to include Foley catheter care, indicating a lapse in the facility's protocol for ensuring comprehensive care upon readmission.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to ensure that a resident with a history of pressure injuries received necessary treatment and services to prevent the development of new pressure injuries and to promote healing. The resident, who was admitted with multiple pressure injuries, developed three new Stage 3 pressure injuries on the coccyx and buttocks. Despite the development of these new injuries, the facility did not revise the resident's care plan to include specific interventions for repositioning frequency or incontinence care, which are critical for pressure injury prevention. The resident was assessed as being at risk for pressure injury development and was always incontinent of bowel and bladder, requiring substantial assistance for mobility and hygiene. However, the care plan lacked detailed instructions on repositioning and incontinence care, and the CNA kardex did not document these necessary interventions. Observations revealed that the resident was often left in the same position for extended periods, and staff did not consistently offer repositioning, which contributed to the development of new pressure injuries. Additionally, there were lapses in communication and documentation regarding the resident's condition. Nurses' notes indicated the presence of excoriation and open areas on the resident's buttocks, but there was no evidence of physician notification or orders for treatment. The facility's failure to update the care plan and ensure proper communication and documentation of the resident's condition contributed to the deficiency in providing adequate pressure ulcer care.
Failure to Update Care Plan and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and update care plans for a resident who experienced a significant change in condition. The resident, who was readmitted to the facility with a decline in cognition and activities of daily living (ADLs), was not provided with an updated care plan or CNA Kardex to reflect these changes. Despite being assessed as requiring maximal assistance with ADLs and having a moderate risk for falls, the care plan and Kardex were not revised to incorporate the recommendations from the hospital occupational therapist. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and was recently diagnosed with possible metastatic lung cancer, was admitted to hospice care. Upon readmission, the resident's cognitive status was impaired, and they required significant assistance with mobility and ADLs. However, the facility did not update the care plan or Kardex to reflect these needs, leading to inadequate supervision and a fall that resulted in a dislocated finger and laceration. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's change in condition. The Director of Nursing and Assistant Director of Nursing were unable to recall specific details about the resident's readmission and changes in condition. The CNA Kardex and care plan remained outdated, failing to provide staff with the necessary information to prevent accidents and ensure the resident's safety.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R5, was assessed by the interdisciplinary team to determine if it was clinically appropriate for her to self-administer medication. R5, who has diagnoses including Guillain-Barre syndrome, diabetes mellitus, and lymphedema, was observed applying Medihoney to her left posterior calf wound without an assessment for her ability to self-administer treatments. The facility's policy requires that a resident may only self-administer medications after the interdisciplinary team has determined it is safe, and this assessment must be documented in the resident's medical record. R5 was found with a clear plastic bag containing various ointments and creams, including Medihoney, which she used for her wound care. Despite her severe cognitive impairment, indicated by a BIMS score of 7, there was no documentation of a self-administration assessment in her medical record. The RN/UM confirmed that R5 had not received any teaching regarding self-administration because she was not supposed to perform her treatments. The facility's failure to conduct and document the necessary assessment led to the deficiency noted by the surveyor.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure prompt resolution of grievances filed by two residents, R1 and R3, as required by their grievance policy. R1's representative reported a missing CPAP machine, which was not documented in the facility's grievance log. Despite multiple notifications to staff, including the Admissions Director and Social Worker, there was no evidence of an investigation or resolution communicated to R1's representative. The facility's policy mandates that grievances be tracked, investigated, and resolved with written decisions issued to the complainant, which was not adhered to in this case. R1 was admitted with several medical conditions, including Chronic Obstructive Pulmonary Disease and Vascular Dementia, and required a CPAP machine for treatment. The representative brought the CPAP machine from home, but it went missing during a transfer within the facility. Despite the facility renting a CPAP machine for R1, there was no follow-up or resolution regarding the missing personal CPAP machine, and the grievance was not documented or investigated as per the facility's policy. Similarly, R3's activated Health Care Power of Attorney reported multiple grievances, including care concerns and missing clothing items, to the Social Worker. These grievances were not documented, investigated, or resolved, and no follow-up was provided to R3's representative. R3 had severe cognitive impairments and required assistance with daily activities, making the lack of response to grievances particularly concerning. The facility's failure to document and address these grievances violated their policy and the residents' rights to voice grievances without fear of reprisal.
Failure to Protect Residents During Abuse Investigations
Penalty
Summary
The facility failed to ensure that all allegations of potential abuse were thoroughly investigated and that residents were protected from further abuse during the investigation process. In the first incident, a resident-to-resident altercation occurred where one resident approached another, pulled their hair, and possibly slapped them. Although the facility submitted the required reports to the State Agency and interviewed staff members, they did not conduct interviews with other residents to determine if there was a pattern of abuse or if other residents had witnessed the altercation. This lack of thorough investigation was highlighted during a surveyor's interview with the Nursing Home Administrator, who could not provide additional information or documentation of resident interviews. In the second incident, a Certified Nursing Assistant (CNA) was accused of verbally abusing a resident by telling them to use their incontinent product and slamming a bedpan on the table. The resident reported the incident to a nurse, and an investigation was initiated. However, the CNA was allowed to continue working on the floor with other residents during part of the shift, which is against the facility's policy of removing the accused employee from resident care areas during an investigation. The Director of Nursing initially allowed the CNA to return to the unit before eventually having them leave the facility. This failure to protect residents during the investigation was confirmed by staff interviews and the facility's documentation. The facility's policies on abuse prevention and investigation were not fully adhered to, as evidenced by the lack of immediate removal of the accused CNA from resident care areas and the incomplete investigation into the resident-to-resident altercation. The facility's policy requires thorough investigations, including interviewing all involved parties and ensuring residents are protected from harm during investigations. The surveyor noted that the facility's policy did not explicitly document the procedure for removing an employee from resident care areas immediately after an allegation is made, which contributed to the deficiency in handling the abuse allegations.
Deficiencies in Resident Care and Assessment
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident R5, who has severe cognitive impairment and multiple diagnoses including Guillain-Barre syndrome and diabetes mellitus, was observed performing her own wound care treatment on her left posterior calf. Despite the physician's order for daily wound care by nursing staff, R5 was found to be self-administering the treatment due to perceived delays in care. The nursing staff, including RN-J, acknowledged that R5 performed her own treatment and signed the treatment administration record (TAR) as if the treatment was completed by staff, which was not in compliance with the facility's policy. Additionally, the facility did not conduct appropriate assessments for Resident R3, who was admitted with severe cognitive impairment and multiple health conditions. R3 was equipped with a wander guard without a completed wandering assessment, and there was no documentation to support the decision for its placement. Furthermore, R3 was identified as a smoker, yet no smoking assessment was completed to determine the safety and supervision needs for smoking. The lack of assessments and documentation regarding R3's wandering and smoking behaviors indicates a failure to adhere to the facility's policies and procedures for managing residents at risk for elopement and smoking-related incidents. The deficiencies highlight the facility's failure to provide care in accordance with residents' comprehensive assessments and care plans. The lack of proper documentation and adherence to policies resulted in residents not receiving the necessary evaluations and interventions to ensure their safety and well-being. The facility's staff, including the Director of Nursing and Nursing Home Administrator, were informed of these issues, but no further information was provided to address the deficiencies at the time of the survey.
Lack of Behavior Monitoring for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R7, was receiving psychoactive medications with proper indications and monitoring. R7 was admitted with diagnoses including Unspecified Dementia with Agitation, Anxiety Disorder, and Disorientation, and was prescribed Donepezil and Olanzapine for dementia-related behaviors. Despite the comprehensive care plan requiring behavior monitoring to determine the effectiveness and side effects of these medications, there was no documented behavior monitoring on R7's Medication Administration Record (MAR) since their admission. During the survey, the Director of Nursing (DON) confirmed that behavior monitoring should be documented every shift on the MAR, but acknowledged that this had been missed for R7. The surveyor observed R7 on multiple occasions resting quietly without signs of distress or adverse behaviors, yet the lack of documented monitoring raised concerns about the appropriateness of the psychoactive medication regimen. The Nursing Home Administrator was informed of the deficiency, but the facility was unable to provide additional information or documentation to address the surveyor's concerns.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of appropriate hand hygiene and personal protective equipment (PPE) usage during incontinence care for a resident identified as R10. The resident, who has diagnoses including major depressive disorder, diabetes mellitus, morbid obesity, and altered mental status, also has Stage 3 pressure injuries on the coccyx and left buttocks, necessitating enhanced barrier precautions (EBP). However, during multiple observations, surveyors noted the absence of EBP signage on R10's door and a PPE cart outside the room, which are required by the facility's policy. On several occasions, surveyors observed that staff members, specifically CNA-G and CNA-H, did not wear gowns while providing incontinence care to R10, who was on EBP. Additionally, CNA-G failed to perform proper hand hygiene after removing gloves and before donning new ones during the care process. This lack of adherence to hand hygiene protocols was confirmed by the surveyor's observations, as hand hygiene was only performed at the end of the care session. When questioned, CNA-G was unable to explain how she knew if a resident was on EBP, indicating a lack of awareness or training regarding the facility's infection control policies. Further interviews with the facility's staff, including the RN/UM, DON, and ADON, revealed inconsistencies in the understanding and implementation of EBP. The RN/UM was not aware that R10 was on EBP, despite the resident's pressure injuries, and there was no clear communication or documentation system in place to inform staff of residents requiring EBP. The DON and ADON acknowledged the deficiencies observed by the surveyor, including the absence of EBP signage and PPE carts, as well as the failure of staff to wear gowns and perform proper hand hygiene during care activities.
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.
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