Avina Of Weyauwega
Inspection history, citations, penalties and survey trends for this long-term care facility in Weyauwega, Wisconsin.
- Location
- 717 E Alfred St, Weyauwega, Wisconsin 54983
- CMS Provider Number
- 525315
- Inspections on file
- 40
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Avina Of Weyauwega during CMS and state inspections, most recent first.
A resident with type 2 DM, multiple pressure injuries, a diabetic foot ulcer, and an abdominal wound was admitted with transfer orders for scheduled and PRN insulin (NPH and Regular), IV cefepime for Pseudomonas skin infection, levofloxacin, and frequent blood glucose monitoring. Facility policies required implementation of signed transfer orders and administration of medications as ordered, but the resident did not receive several ordered therapies: NPH insulin was held due to lack of stock and then discontinued, Regular insulin doses were missed before meals, levofloxacin and IV cefepime were not started until the day after admission, and ordered fingerstick glucose checks were missed after supper and the following breakfast. The Regional Director of Operations later confirmed that staff had missed these orders and that the medications and monitoring were not provided as prescribed.
A resident with COPD, heart disease, bipolar disorder, and pain disorder, who was cognitively intact and receiving multiple sedating medications (including scheduled lorazepam, gabapentin, acetaminophen, and PRN morphine), became lethargic, diaphoretic, and minimally responsive, leading to transfer to the ER. The MAR sent with the resident showed that HS medications had been administered, but the ADON later found those medications still in the med cart. An RN acknowledged documenting the HS medications as given on the MAR before attempting administration and then encountering the resident sweaty and refusing the medications. Leadership confirmed that documenting medications as administered prior to actually giving them was contrary to facility policy.
A resident with an indwelling urinary catheter received catheter care from staff without an active physician order in place. The care plan noted the catheter, but no current orders for the catheter or its care were found, and staff did not document catheter care due to the missing order. Staff interviews confirmed that care was provided without verifying or obtaining the necessary physician order.
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.
The facility did not complete the care plan within 7 days of the comprehensive assessment and did not ensure that a team of health professionals prepared, reviewed, and revised the care plan as required.
A resident with a mental disorder, psychosocial adjustment difficulty, or a history of trauma and/or PTSD did not receive the necessary treatment and services to address their condition, resulting in a deficiency related to inadequate mental health and psychosocial care.
Staff did not follow infection control protocols during care for three residents, including failing to remove PPE when exiting a precaution room, not donning required gowns during transfers, not sanitizing shared equipment, and neglecting hand hygiene and glove changes during pericare. Clean items were contaminated by soiled gloves, and a used bed pan was improperly stored on the floor.
Two residents were exposed to accident hazards due to the facility's failure to enforce its smoking policy and elopement prevention measures. One resident repeatedly smoked in their room, with no updates to their care plan despite multiple violations and a history of fire-related incidents. Another resident, with cognitive impairment and a history of wandering, was found without a required WanderGuard device and was able to exit the building unsupervised, with staff failing to document or report these incidents. These actions and inactions resulted in immediate jeopardy findings.
Three residents receiving IV antibiotics experienced significant medication errors, including missed doses, unauthorized changes to physician orders, and lack of physician notification when doses were not administered. In each case, staff failed to clarify medication orders, did not follow proper procedures for order changes, and did not document or communicate missed doses to the appropriate medical providers.
The facility failed to maintain sanitary food preparation and dishwashing practices, including improper hand hygiene by kitchen staff during a Norovirus outbreak, lack of testing and logging for sanitizer bucket effectiveness, and inaccurate monitoring of dishwashing machine temperatures. Staff were observed handling dirty and clean dishes without proper handwashing or changing aprons, and logs for critical sanitation checks were either missing or falsified.
A facility failed to maintain an effective infection prevention and control program during a GI illness outbreak, with incomplete outbreak documentation, premature removal of residents from contact precautions, and inconsistent use of PPE and hand hygiene. Staff did not follow protocols for handling soiled linens, sanitizing shared equipment, or updating public health authorities, and there were discrepancies in illness tracking among staff. These lapses affected residents with various medical conditions and had the potential to impact all individuals in the facility.
Multiple residents reported excessive delays in call light response and assistance with basic needs, including toileting and feeding, due to insufficient nursing staff. Observations confirmed that only one CNA was present in the dining room to assist several residents, leading to delays in feeding and unmet requests for water. Staffing schedules showed that staff-to-resident ratios frequently fell below the facility's own guidelines, with as few as two staff members covering over 50 residents during some night shifts.
Surveyors found that medication carts were left unlocked and unattended, with resident information visible, and that narcotic medications were stored unsecured at the nurses' station. Additional issues included improperly labeled, undated, and expired medications in a medication cart, as well as expired medical supplies and an unlabeled pill container in a medication storage room. Staff interviews confirmed these practices did not follow facility policy for medication security and labeling.
Two residents did not receive timely or properly documented wound care, with one not having wounds assessed or treated upon admission and another having a dressing applied without a physician order or documentation. Staff interviews and record reviews confirmed lapses in following wound care protocols and documentation requirements.
A resident admitted with sepsis, diabetes, and a pre-existing pressure injury did not receive timely or accurate skin assessments or wound care. The facility failed to document all wounds, delayed obtaining wound care orders, and did not provide necessary treatments, resulting in incomplete care and lack of evidence regarding the number and status of pressure injuries.
A resident with an activated POAHC following hospitalization for sepsis was allowed to sign multiple consent forms upon readmission, despite a Statement of Incapacity in the medical record. Facility staff failed to recognize and act on the POAHC status, and the resident's representative was not notified of the activation until later. Staff interviews revealed a lack of awareness and inconsistent review of advance directive paperwork, resulting in the resident's representative not being able to exercise the resident's rights.
The facility did not ensure PASRR requirements were met for two residents with mental illness who were admitted under a 30-day hospital discharge exemption. Both residents' records lacked the required County exemption form and timely PASRR Level II Screens, with documentation only submitted after surveyor inquiry.
A resident with CHF did not receive a required physician visit according to the facility's alternating schedule, as only nurse practitioner visits were documented during the relevant period. Attempts by the physician to see the resident were not documented in the medical record, and the absence of a completed physician visit note led to a deficiency.
Three residents were found with medications at their bedside without proper physician orders or documented self-administration assessments, and one resident did not receive prescribed bedtime medications with no timely physician notification. Facility policy requires orders and assessments for self-administration and bedside storage, which were not completed for all medications involved.
Two residents who had provided consent for influenza and pneumococcal vaccines did not receive the immunizations as indicated in their records. One resident with Parkinson's disease and a POAHC consented to the flu vaccine, while another with CHF consented to the pneumococcal vaccine; both vaccines were not administered despite proper documentation and eligibility.
A resident with COPD and moderate cognitive impairment, whose POAHC provided signed consent for a COVID-19 vaccine, was not administered the vaccine by facility staff. The medical record lacked documentation of vaccine administration, and the Infection Preventionist confirmed the vaccine was not given.
The facility did not ensure that all staff, including several CNAs, received mandatory annual training on the Quality Assurance and Performance Improvement (QAPI) program as required by facility policy. Review of staff education records and administrator confirmation showed that QAPI education was not included in the training provided.
A resident requested a copy of their medical record, which was not provided within the facility's policy timeframe of 7 days. Instead, the record was mailed 25 days later. The Medical Records Coordinator cited workload and administrative review as reasons for the delay, while the Nursing Home Administrator believed requests should be fulfilled within 10 days, indicating a lack of adherence to policy.
The facility failed to maintain proper infection control practices for two residents. A resident with a suprapubic catheter did not receive care with the required gown use by a CNA, despite being on enhanced barrier precautions. Another resident, with multiple diagnoses and on EBP, did not receive proper hand hygiene and glove changes during care. Both deficiencies were confirmed by the DON and IP.
A resident with Parkinson's disease and psychosis did not receive proper monitoring and administration of clozapine due to an incorrect lab order and missed doses. This led to the resident experiencing psychosis symptoms and requiring emergency room treatment. Staff interviews revealed a lack of awareness and education regarding the specific lab requirements for clozapine monitoring.
The facility failed to provide sufficient nursing staff, resulting in delayed care for residents. Multiple residents reported long wait times for call light responses, leading to incontinence and missed medications. Staff interviews confirmed the challenges of inadequate staffing, with agency staff often not showing up or leaving mid-shift. Despite management's claims of sufficient staffing, the lack of timely care persisted, affecting residents' quality of life.
A resident with Parkinson's disease and psychosis did not receive clozapine for four days, and the neurologist was not notified, contrary to facility policy. The resident, who had moderately impaired cognition, was hospitalized for increased behavioral symptoms, including attempting to ingest lotion. A neurology RN confirmed the neurologist was unaware of the missed doses, which are critical due to the medication's monitoring requirements.
The facility failed to provide appropriate care for three residents, including improper management of a DBS for a resident with Parkinson's, lack of updated assessments for a resident with cognitive decline, and inadequate oral care for a resident with fungal candidiasis. Staff were unaware of device functions, did not reassess consent capacity, and deviated from care plans, leading to deficiencies in resident care.
A resident fell due to improper transfer methods not aligned with their care plan, highlighting deficiencies in staff training and adherence to safety protocols. Additionally, the facility charged motorized wheelchair batteries in a poorly ventilated room, posing a fire hazard.
The facility failed to ensure accurate medication administration for two residents. One resident received multiple medications late over several days, while another did not receive scheduled pain medication on a night shift, leading to increased pain. Additionally, medications were left unsupervised with a resident who lacked a self-administration assessment. The facility's policies were not adhered to, resulting in these deficiencies.
A facility failed to report an alleged verbal abuse incident involving a CNA and a cognitively impaired resident to local law enforcement, as required by their policy. The incident was reported internally, and the accused CNA was suspended and later returned to work after completing relevant education. However, the Nursing Home Administrator did not notify law enforcement, resulting in a deficiency noted by surveyors.
A resident with a history of chronic respiratory failure and anxiety reported difficulty breathing and feeling like they were having a stroke. Despite these symptoms, nursing staff failed to adequately assess the resident or notify a physician. The resident's condition was not communicated to the night shift, and they were found unresponsive the following day, leading to a finding of immediate jeopardy due to the facility's failure to provide appropriate care.
The facility failed to ensure competent staff performed nail care and vital signs for residents. A resident on anticoagulant medication had their nails trimmed by a non-certified Hospitality Aide (HA), and multiple residents had their vital signs taken by HAs not enrolled in a CNA course. The Director of Nursing confirmed that HAs were not supposed to perform these tasks, and inconsistencies in task delegation were noted among staff.
Missed Insulin, IV Antibiotics, and Glucose Monitoring After Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmacy services and accurate medication administration for a newly admitted resident with multiple complex medical conditions, including type 2 diabetes, protein calorie malnutrition, venous stasis dermatitis with ulcer, stage 3 pressure injuries on both thighs, a diabetic foot ulcer, and an abdominal wound. Facility policies required that admission and transfer orders be implemented to allow essential care and that medications be administered according to physician orders, including implementing signed transfer orders from a hospital without further validation. The resident’s discharge medication list from the sending facility included scheduled and PRN insulin (NPH and Regular), IV cefepime for Pseudomonas skin infection, levofloxacin, and blood glucose testing three times daily. Record review showed that after admission, multiple ordered medications and treatments were not provided as prescribed. NPH insulin ordered for morning administration with an additional HS PRN dose was not given on the first day and was documented as held because the insulin was not in contingency stock; the physician was notified and the insulin was later discontinued. Regular insulin ordered three times daily before meals was not administered for three doses and was not started until the following day in the evening. Levofloxacin 750 mg ordered once daily at bedtime was not given on the first night and was not started until the next day. IV cefepime ordered twice daily was not administered for the first scheduled bedtime dose and the following morning dose, with the first dose given the next evening. Ordered fingerstick blood glucose monitoring four times daily was also missed after supper on the first day and after breakfast the next morning. During interview, the Regional Director of Operations was uncertain whether staff were aware of the insulin, blood glucose monitoring, IV cefepime, and levofloxacin orders and confirmed that these orders were missed and the medications were not administered as prescribed on the first day.
Inaccurate MAR Documentation for Bedtime Medications
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure accurate documentation of medication administration for one resident. The facility’s medication administration policy required licensed nurses to administer medications as ordered, sign the MAR after administration, and document refusals. The resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including COPD, heart disease, bipolar disorder, and pain disorder, was ordered multiple sedating and pain medications, including scheduled lorazepam at bedtime, acetaminophen and gabapentin three times daily, and PRN morphine. On the night in question, the resident became lethargic, diaphoretic, minimally responsive to sternal rub, non-verbal, and unable to keep their eyes open, prompting staff to call 911 and send the resident to the ER. Documentation sent with the resident to the ER, specifically the MAR, indicated that the resident’s bedtime medications had been administered, but subsequent review and interviews revealed they had not been given. The ADON reported receiving conflicting accounts about whether the HS medications were administered and later located the HS medications still in the medication cart, while confirming that the MAR sent to the ER showed them as given. The RN on duty admitted that she documented the HS medications as administered on the MAR before attempting to give them and that, when she went to administer them, the resident was sweaty and refused the medications. The DON and ADON both confirmed that staff should not document medications as administered prior to actually administering them and that nursing staff were expected to follow the facility’s medication administration policy.
Lack of Physician Order for Indwelling Catheter and Catheter Care
Penalty
Summary
A resident with a diagnosis of benign prostatic hyperplasia was admitted and later readmitted to the facility with an indwelling urinary catheter. The resident's care plan documented the presence of the catheter and included interventions to monitor for discomfort, leaking, and obstruction. However, a review of the physician orders revealed there were no current orders for the urinary catheter or for catheter care. Staff provided catheter care without verifying the existence of an active physician order, and no documentation of catheter care was made on the Treatment Administration Record due to the absence of such an order. During interviews, staff acknowledged that they did not check for a current order before providing care and that clarification should have been sought upon the resident's readmission.
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 Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. Additionally, the care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the surveyor's review of facility practices and documentation.
Failure to Provide Appropriate Mental Health and Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed or was diagnosed with a mental disorder, psychosocial adjustment difficulty, or had a history of trauma and/or post-traumatic stress disorder. The deficiency was identified based on the lack of evidence that the resident received necessary care and interventions tailored to their mental health and psychosocial needs, as required by regulatory standards.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols for three residents during care activities. For one resident on enhanced barrier precautions (EBP), staff exited the resident's room without removing personal protective equipment (PPE), re-entered the room without donning new PPE, and transferred the resident using a lift without wearing required gowns. Additionally, the lift was not sanitized after use and was left in the hallway. Staff interviews confirmed knowledge of the correct procedures, but these were not followed during the observed events. During pericare for two other residents, staff did not change gloves or perform hand hygiene between dirty and clean tasks, and touched clean items in the residents' rooms with soiled gloves. In one instance, a used bed pan was stored on the floor of a resident's room. In another, clean washcloths were placed in an unsanitized sink and then used for pericare. Staff interviews confirmed that these actions were inconsistent with facility policy and proper infection control practices.
Failure to Prevent Accident Hazards: Unsafe Smoking and Elopement
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents, resulting in deficiencies related to unsafe smoking practices and inadequate elopement prevention. One resident, who was cognitively intact and had a history of noncompliance with smoking policies, repeatedly smoked cigarettes in their room despite the facility's policy requiring smoking only in designated areas. The resident's care plan was not updated in response to multiple documented violations, and staff failed to revise the smoking assessment or implement additional safety interventions after incidents, including one where a hot cigarette butt singed trash in a shared bathroom. The resident's medical record also indicated a history of disruptive behavior and previous fire-related incidents in another facility, yet the facility did not adjust the care plan or restrict access to smoking materials accordingly. Another resident, with moderate cognitive impairment and a history of exit-seeking behavior, was not adequately supervised to prevent elopement. The resident's care plan required the use of a WanderGuard device and securing the window to prevent unsupervised exits. However, staff failed to ensure the WanderGuard was consistently in place and functioning, and the window in the resident's room was found to open fully, contrary to care plan instructions. The resident was observed without a WanderGuard on multiple occasions and was able to exit the building unsupervised through an emergency exit. Staff interviews revealed that the resident frequently removed the WanderGuard, and incidents of elopement were not documented or reported to administration as required. The facility's inaction in revising care plans, conducting new assessments, and ensuring the implementation of safety interventions for both residents led to a finding of immediate jeopardy. The lack of supervision and failure to enforce policies regarding smoking and elopement prevention created a situation where residents, including those with physical and cognitive limitations, were exposed to significant safety risks. Documentation and communication lapses further contributed to the ongoing deficiencies.
Removal Plan
- Remove smoking materials from R19's room and store them in a locked area.
- Reeducate R19 and have R19 sign the facility's smoking policy and behavior contract for smoking.
- Place R19 on checks to ensure smoking materials are not found in R19's room.
- Revise R19's care plan to reflect R19's current smoking plan.
- Update the facility's smoking policy to include information on where smoking materials will be kept to maintain safety and reduce the risk of unsafe smoking.
- Educate residents who smoke on the facility's smoking policy, review the designated smoking area, and collect all smoking materials for safe storage.
- Educate staff on the facility's smoking policy and procedure.
- Initiate audits to ensure all smoking materials remain locked and the smoking policy is being followed.
- Place a WanderGuard on R27 and review R27's order to ensure staff check placement, location, and function.
- Place R27 on checks to monitor R27's location and ensure safety.
- Secure the window in R27's room.
- Revise R27's care plan with updated interventions.
- Review residents at risk for elopement to ensure interventions are appropriate and in place.
- Educate staff on the facility's elopement policy and the importance of monitoring for exit seeking behavior.
- Educate staff on the importance of checking for WanderGuard placement and function.
- Review the facility's elopement policy to ensure information is included regarding what to do when a resident removes a WanderGuard.
- Initiate audits to ensure WanderGuards are in place and functioning properly.
Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
Three residents receiving intravenous (IV) antibiotics experienced significant medication errors due to failures in medication order clarification, unauthorized changes to physician orders, and missed doses. One resident was admitted with a complex medical history including osteomyelitis, bacteremia, and acute kidney injury, and had a hospital discharge order for IV cefepime. Staff did not recognize a dosing error in the discharge order and entered it incorrectly into the facility's system. Subsequently, a registered nurse changed the order without consulting a physician, resulting in discrepancies between the hospital discharge order, the facility physician's order, and the nurse's revised order. The resident missed three doses of IV antibiotics over four days, and there was no documentation that the physician was notified of these missed doses. Another resident with multiple chronic conditions, including pneumonia, MRSA infection, and diabetic foot ulcer, had a physician order for IV vancomycin. The medication administration record (MAR) showed that a scheduled dose was not administered, and there was no documentation that the physician was notified of the missed dose. Additionally, a change in the administration time was communicated to the infectious disease office, but subsequent missed doses were not reported to the physician. A third resident with diagnoses including bacteremia, osteomyelitis, and diabetes was prescribed IV ceftriaxone via a PICC line. The MAR indicated that a scheduled dose was not administered because the resident was away from the facility for a physician appointment. There was no documentation that the physician was notified of the missed dose, and the facility physician confirmed that they were not made aware of the missed administration. In all cases, the facility failed to ensure that IV antibiotics were administered as ordered and that physicians were notified when doses were missed.
Removal Plan
- Review R203's medication orders for accuracy and availability and notify Infectious Disease (ID) of missed doses.
- Audit all residents on antibiotics and verify their medications are available and being administered.
- Educate nursing staff on the facility's policy for administering medication per physician orders and what to do when medications are unavailable.
- Educate nursing staff on confirming pharmacy orders with the physician and that nurses may not change medication orders without physician approval.
- Initiate audits to ensure admission orders are transcribed correctly and have been received from the pharmacy.
Deficient Sanitary Practices in Food Preparation and Dishwashing
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, as evidenced by multiple breaches in hand hygiene, improper monitoring of sanitizing solutions, and inadequate dishwashing practices. During an active Norovirus outbreak affecting both staff and residents, kitchen staff were observed not following proper handwashing protocols. Specifically, a staff member washed hands in a bucket of dirty water containing used silverware and then wiped hands with a cloth, rather than using the designated handwashing sink. Another staff member admitted to forgetting to wash hands after handling dirty dishes and before handling clean items. The facility was unable to provide a kitchen-specific hand hygiene policy when requested, instead providing a policy intended for nursing staff. Sanitizing solutions used in the kitchen were not properly tested or logged for effectiveness. Staff did not test the sanitizer buckets for the required parts per million (PPM) concentration or temperature, and there was no log maintained for these checks. Although the three-compartment sink was tested, the sanitizer buckets, which were used for cleaning surfaces and utensils, were not. Staff and the Dietary Manager confirmed that testing and logging of sanitizer buckets was not being performed as required by the FDA Food Code and manufacturer instructions. Dishwasher temperatures were not accurately monitored or maintained. The dishwashing machine's temperature gauge was known to be faulty, and staff relied on paper test strips that only indicated if the temperature was above 180°F, without providing an exact reading. Staff admitted to recording inaccurate temperatures on logs, and the Dietary Manager was aware that the logs did not reflect actual temperatures. The dishwashing machine consistently failed to reach the required sanitizing temperature, and this issue had been ongoing, as documented in previous reports and discussed in Quality Assurance meetings. Additionally, staff were observed moving from handling dirty dishes to clean dishes without changing aprons or washing hands, further compromising sanitary practices.
Failure to Maintain Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in following established protocols during a gastrointestinal (GI) illness outbreak and in the management of multidrug-resistant organisms (MDROs). The outbreak line lists for both staff and residents were incomplete, lacking critical information such as the date and time of last symptoms, which is necessary to determine the appropriate duration for contact precautions and staff exclusion from work. As a result, two residents were removed from contact precautions prematurely, contrary to facility policy, and the County Health Department was not updated on new cases as required. Additionally, discrepancies existed between the staff illness line list and the human resources call-in list, further complicating outbreak management. Staff did not consistently adhere to infection control protocols related to enhanced barrier precautions (EBP) and contact precautions. For example, an LPN failed to wear a gown while manipulating a resident's clothing to administer a pain patch, despite the resident being on EBP for MDRO colonization. Staff also entered a resident's room on contact precautions without donning personal protective equipment (PPE), and soiled linens were transported through hallways without being properly bagged, increasing the risk of cross-contamination. Furthermore, staff did not sanitize shared equipment, such as a mechanical lift, after use with a resident on EBP, and hand hygiene was not offered to residents before or after meals during an active Norovirus outbreak. Observations and interviews revealed a lack of understanding and inconsistent application of infection control policies among staff, including the handling of soiled linens, use of PPE, and adherence to hand hygiene protocols. Residents with cognitive impairments and those responsible for their own healthcare decisions were affected by these lapses. The facility's own policies, which align with state and federal regulations and national guidelines, were not followed, resulting in practices that had the potential to affect all residents in the facility.
Insufficient Nursing Staff Resulting in Delayed Resident Care and Unmet Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple resident interviews, staff interviews, observations, and record reviews. Several residents reported excessive wait times for call light responses, with some waiting up to three hours for assistance with toileting and other needs. One resident, who takes a diuretic, reported being unable to use a urinal for up to three hours, while another resident with a recent above-the-knee amputation described being left in a wet bed and not receiving timely toileting assistance. Additional residents reported being told to soil themselves due to lack of available staff, and one resident experienced incontinence and humiliation after waiting an hour and a half for help during a diarrhea episode. Observations in the dining room revealed that only one CNA was present to assist seven residents during breakfast, resulting in delays in feeding assistance and residents receiving cold food. Two residents who required feeding assistance had to wait until all other residents were served, and another resident repeatedly requested water but did not receive it because the CNA was occupied. The CNA confirmed that staffing was insufficient in the dining room, as CNAs were required to cover both the dining room and resident units, leading to delays in care and unmet needs. A review of the facility's staffing schedules and Facility Assessment showed that staffing levels frequently fell below the recommended ratios based on resident acuity and census. On several occasions, there were only two staff members (one CNA and one LPN) available for over 50 residents during the night shift, resulting in staffing hour ratios as low as 2.51, which was below the facility's own assessment guidelines. The Nursing Home Administrator acknowledged that staffing levels were not consistently maintained according to the facility's assessment and resident needs.
Medication Storage, Labeling, and Security Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage and labeling practices. Medication carts in the B wing and near the nurses' station were found unlocked and unattended, with one cart displaying resident information on an open computer screen facing the hallway. Staff interviews confirmed that medication carts should be locked when not attended and that resident information should not be left visible. Additionally, several medication cards, including schedule two narcotics, were found unsecured in an unlocked desk drawer at the nurses' station, rather than in a locked area as required by facility policy. Staff acknowledged that these medications had been delivered from the pharmacy and should have been secured until counted at shift change. Further deficiencies were identified in the E wing medication cart, which contained multiple medications that were open and undated, including insulin vials, artificial tears, inhalers, and nasal sprays. Some medications lacked resident names, and at least one bottle of vitamin C was expired. Staff confirmed that these medications were not labeled or dated appropriately and that expired medications were present. The D wing medication storage room also contained numerous expired medical supplies and medications, as well as an unlabeled pill container with unknown contents and no resident identification. Facility policies reviewed by surveyors required that all drugs and biologicals be stored in locked compartments, with controlled substances in separately locked areas, and that medications be properly labeled and dated. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the observed practices did not align with facility protocols, as medications and resident information were not properly secured, and expired or unlabeled items were not removed from storage.
Failure to Provide Timely and Documented Wound Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate wound care and timely skin assessments for two residents, resulting in deficiencies related to wound management. One resident was admitted with multiple wounds, including ulcers and abrasions, and had a history of sepsis and diabetes. Despite clear documentation from the hospital and an advanced practice nurse indicating the need for wound care, the facility did not complete a timely or accurate skin assessment upon admission. Wound care orders were not obtained until several days after admission, and the resident did not receive any wound care during their stay. The treatment administration record did not align with the actual wounds present, and there was a lack of documentation for certain wounds requiring care. Another resident had a sore on the left lower shin, which was observed to have a dressing that was not initialed or dated. The medical record did not contain an order for this dressing, nor did it document the presence of a wound on the left lower shin. Skin checks in the record failed to note any skin impairments, and the wound was not included on the wound boards for review. The wound care nurse confirmed there was no documentation or treatment order for the area until after the issue was brought to attention during the survey. Interviews with staff and residents confirmed that wound care was either not provided or not documented as required. The facility's policy required verification of physician orders and documentation of dressing changes, but these steps were not consistently followed. The lack of timely assessment, absence of treatment orders, and failure to document wound care contributed to the deficiencies identified during the survey.
Failure to Provide Timely and Accurate Pressure Ulcer Care
Penalty
Summary
A resident was admitted to the facility with a history of sepsis, type 2 diabetes, and an existing pressure injury on the right buttock. Upon admission, the resident was assessed as being at risk for pressure injuries, and hospital records indicated the presence of a pressure injury prior to arrival. Despite this, the facility did not complete a thorough or timely skin assessment, as the initial skin map failed to document any skin issues, and the wound evaluation did not accurately reflect all existing wounds. The care plan was updated to include interventions such as a pressure-relieving air mattress and turning/positioning, but it did not specifically address all identified wounds, including a pressure injury on the right hip. Orders for wound care were not obtained until several days after admission, and there was confusion among staff regarding the documentation and location of the wounds. The resident reported that wound care was not provided during their stay, and staff confirmed that no wound care was administered due to the lack of timely physician orders. Interviews with facility leadership and nursing staff revealed that the required skin assessments were not completed within the expected timeframe, and there was a lack of clarity regarding the number and location of the resident's pressure injuries. The facility was unable to provide evidence of comprehensive wound assessment or care during the resident's stay, resulting in a failure to provide necessary care and services to promote healing and prevent the development of new pressure injuries.
Failure to Follow Activated POAHC and Notify Resident Representative
Penalty
Summary
The facility failed to ensure that an activated Power of Attorney for Healthcare (POAHC) was properly recognized and followed for one resident. The resident, who had diagnoses including depression, malnutrition, type two diabetes, and obstructive uropathy, was admitted with an activated POAHC after returning from a hospital stay for urinary sepsis. Despite a Statement of Incapacity signed by two medical providers and included in the hospital discharge paperwork, the facility allowed the resident to sign multiple consent forms upon readmission, treating the resident as their own decision maker. The POAHC was not notified of the activation until a later date, and staff interviews revealed a lack of awareness and understanding regarding the resident's capacity status and the proper procedures for reviewing advance directive paperwork during admission. Staff responsible for the resident's admission and care, including the LPN, Social Services Director, and Medical Records Nurse, demonstrated inconsistent knowledge and communication regarding the resident's POAHC status. The LPN confirmed that the POAHC should sign consents if activated but was unsure about reevaluation procedures for capacity. The Social Services Director and POAHC were both unaware of the activation at the time of care planning discussions. The Medical Records Nurse only discovered the Statement of Incapacity when scanning hospital discharge paperwork and subsequently notified the LPN. This series of oversights resulted in the resident's representative not being given the opportunity to exercise the resident's rights as required.
Failure to Complete PASRR Requirements for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) requirements were met for two residents with mental illness who were admitted under a 30-day hospital discharge exemption. For one resident with a diagnosis of bipolar disorder and moderate cognitive impairment, the medical record included a PASRR Level I Screen indicating a major mental disorder and a 30-day exemption, but did not contain the required County form F-20822 or a PASRR Level II Screen. The Social Services Director reported submitting the exemption request but did not receive confirmation, and the Level II Screen was only submitted after the surveyor's inquiry. Similarly, another resident with adjustment disorder and depression, who was receiving duloxetine, had a PASRR Level I Screen indicating mental illness and a 30-day exemption, but the medical record lacked both the required exemption form and a PASRR Level II Screen. The Social Services Director also stated that the exemption request was submitted without confirmation and the Level II Screen was not obtained until prompted by the surveyor. These omissions resulted in the facility not meeting federal and state PASRR requirements for residents with mental illness.
Failure to Ensure Timely Physician Visits for Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with congestive heart failure received timely physician visits as required by federal and state regulations. The facility's policy mandates that residents must be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter, with the option for alternating visits by a physician extender after the initial visit. Record review showed that the resident was seen by a physician in late November and December, and by a nurse practitioner in January, February, and March. However, there was no documentation of a physician visit in February, as required by the alternating schedule. Interviews with the Nursing Home Administrator revealed that the physician attempted to see the resident on two occasions in January, but the resident was not present due to attending dialysis appointments. The administrator provided a hand-written note indicating attempted visits, but confirmed that only completed visits are documented in the medical record system, and there was no physician visit note available for February. The lack of documentation and absence of a physician visit in February led to the deficiency.
Failure to Ensure Proper Medication Orders and Assessments for Bedside Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents by not ensuring proper physician orders and assessments for self-administration and bedside storage of medications. One resident was observed with melatonin gummies at the bedside without a physician order or a documented self-administration assessment. This resident also did not receive prescribed bedtime medications on a specific date, and there was no documentation that the physician was notified of the missed doses. The resident had intact cognition and made their own medical decisions, but the required processes for self-administration and bedside medication storage were not followed. Another resident was found with a bottle of bovine collagen pills, liquid Imodium, and two albuterol inhalers at the bedside. While the care plan and assessments allowed for self-administration of certain medications, there was no physician order or assessment permitting the resident to keep Imodium at the bedside or to self-administer it. The resident had intact cognition, and the care plan specified which medications could be self-administered, but Imodium was not included among them. A third resident was observed with triamcinolone cream, lidocaine ointment, and elderberry immune health pills at the bedside. The medical record did not contain a physician order or self-administration assessment for these medications to be kept at the bedside. The resident had intact cognition, and the care plan and assessments addressed self-administration for some medications, but not for all those found at the bedside. The facility's policies require physician orders and interdisciplinary team assessments for self-administration and bedside storage, which were not completed for these medications.
Failure to Administer Vaccines After Consent
Penalty
Summary
The facility failed to ensure that two residents received influenza or pneumococcal vaccines as indicated by their consent and eligibility. One resident, who had moderate cognitive impairment and an activated Power of Attorney for Healthcare (POAHC), was admitted with a diagnosis of Parkinson's disease. The POAHC provided verbal consent for the resident to receive the influenza vaccine, as documented on the Vaccine Administration Record-Immunization Consent Form. However, the medical record did not show that the influenza vaccine was administered to this resident. Another resident, who was cognitively intact and responsible for their own healthcare decisions, was admitted with a diagnosis of congestive heart failure. This resident signed an Authorization and Release form consenting to receive a pneumococcal vaccine. Despite this, the medical record did not indicate that the pneumococcal vaccine was administered. In both cases, the Infection Preventionist confirmed during interviews that the residents should have received the respective vaccines but did not.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
A resident with chronic obstructive pulmonary disease (COPD) and moderate cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 10 out of 15, was admitted to the facility with an activated Power of Attorney for Healthcare (POAHC) responsible for healthcare decisions. The POAHC provided signed consent for the resident to receive a COVID-19 vaccine, as documented in an undated Authorization and Release for COVID-19 Vaccine form. Despite this consent, the facility did not administer the COVID-19 vaccine to the resident, and there was no documentation in the medical record indicating that the vaccine was given. During an interview, the Infection Preventionist confirmed that the resident should have received the vaccine but did not.
Failure to Provide Required QAPI Training to Staff
Penalty
Summary
The facility failed to provide required annual training on its Quality Assurance and Performance Improvement (QAPI) program to staff, including several Certified Nursing Assistants (CNAs). The facility's QAPI plan specifies that all employees, departments, and services are to be included in the program, and that leadership is responsible for ensuring staff receive necessary technical training. Upon review of staff education records, it was found that the education provided to selected CNAs did not include QAPI program education. The Nursing Home Administrator confirmed that these staff members had not received the required QAPI training, despite the expectation that they should have.
Delayed Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to a medical record for a resident, identified as R2, who requested a copy of their medical record in writing on January 3, 2025. According to the facility's Medical Records policy, a copy should be provided within 7 working days. However, R2's medical record was not mailed until January 28, 2025, which was 25 days after the request. This delay was not in accordance with the facility's policy. R2, who was responsible for their healthcare decisions and had a BIMS score indicating no cognitive impairment, was discharged from the facility on January 6, 2025. During the survey, the Medical Records Coordinator (MRC-C) confirmed the delay and stated that the facility does not have a designated timeframe for fulfilling records requests, which can take a month or more due to the volume of records and the need for administrative review. The Nursing Home Administrator (NHA-A) believed that records requests should be fulfilled within 10 days, indicating a lack of clarity and adherence to the facility's policy. The deficiency was identified through staff interviews and record reviews, highlighting a failure in the facility's process for handling medical record requests.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in deficiencies observed in the care of two residents. Resident 5, who had a suprapubic catheter and was on enhanced barrier precautions (EBP), did not receive appropriate care as Certified Nursing Assistant (CNA)-D did not wear a gown during high-contact care activities. This was despite the presence of an EBP sign outside the resident's room, which should have prompted the use of additional personal protective equipment (PPE) such as gowns. The Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that CNA-D should have worn a gown during these care activities. Similarly, Resident 6, who had multiple diagnoses including peripheral vascular disease and was a carrier of carbapenem-resistant Acinetobacter baumannii, was also on EBP. During a bed bath, CNA-E failed to perform proper hand hygiene and glove changes when applying barrier cream after cleaning the resident's peri-area. This lapse in infection control practices was acknowledged by both the DON and the IP, who agreed that CNA-E should have removed gloves, completed hand hygiene, and donned new gloves before applying the cream.
Failure in Monitoring and Administration of Psychotropic Medication
Penalty
Summary
The facility failed to ensure proper monitoring and administration of psychotropic medication for a resident diagnosed with Parkinson's disease, anxiety, hallucinations, and malnutrition. The resident had an order for clozapine, a medication for psychosis, which required weekly monitoring through a complete blood count (CBC) with differential. On a specified date, the facility staff incorrectly ordered a CBC without differential, leading to the resident missing eight doses of clozapine over several days. This lapse in medication administration resulted in the resident experiencing symptoms of psychosis, including standing on their bed, attempting to ingest non-food items, and exhibiting excessive drooling and frothing from the mouth. The deficiency was further compounded by the lack of awareness and education among the nursing staff regarding the specific lab requirements for clozapine monitoring. Interviews with various staff members, including registered nurses and a consultant pharmacist, confirmed that the incorrect lab draw and subsequent missed doses of clozapine significantly increased the likelihood of the resident's psychosis symptoms. The resident was eventually sent to the emergency room for treatment and returned to the facility after receiving care. The facility's failure to adhere to the physician's orders for lab monitoring and medication administration directly contributed to the resident's adverse health event.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of delayed care and unmet needs. Residents reported significant delays in response to call lights, with some waiting over an hour for assistance. This delay in care led to instances of incontinence and missed medications, as residents were unable to receive timely help for toileting and pain management. The facility's staffing plan indicated a range of licensed nursing and nurse aides required, but observations and interviews revealed that these staffing levels were not consistently met, particularly during night shifts. Residents with various medical conditions, including chronic pulmonary edema, diabetes, and cerebrovascular accidents, were affected by the staffing shortages. These residents, who were not cognitively impaired, expressed frustration over the lack of timely care. For instance, one resident reported waiting over an hour for call light responses, leading to incontinence, while another resident experienced delays in receiving pain medication, resulting in prolonged discomfort. Staff interviews corroborated these accounts, highlighting the challenges faced due to insufficient staffing, such as the inability to complete scheduled tasks and the need to pass tasks to subsequent shifts. Staff members, including CNAs and LPNs, reported being overwhelmed by the workload, with some shifts staffed by only one CNA per wing. Agency staff frequently failed to show up or left mid-shift, exacerbating the staffing issues. Despite these challenges, management reportedly denied any staffing concerns and claimed that there was always a nurse available to assist. However, the lack of a call light log and the consistent reports of delayed care suggest that the facility did not adequately address the staffing deficiencies, impacting the quality of care provided to residents.
Failure to Notify Neurologist of Missed Clozapine Doses
Penalty
Summary
The facility failed to notify a neurologist when a resident did not receive their prescribed medication, clozapine, for four consecutive days. This medication is an antipsychotic used to treat psychosis related to Parkinson's disease. The resident, who had diagnoses including Parkinson's disease, anxiety, hallucinations, and malnutrition, was admitted to the facility with a moderately impaired cognition as indicated by a BIMS score of 12 out of 15. The facility's policy required consultation with a resident's physician within 24 to 48 hours when there is a significant alteration to a resident's treatment, but this was not followed. The resident missed a total of eight doses of clozapine from November 23 to November 26, 2024, and was subsequently hospitalized for increased behavioral symptoms, including attempting to ingest lotion. During an interview, a neurology RN confirmed that the neurologist was not informed about the missed doses of clozapine, which is a highly monitored medication. The failure to notify the neurologist about the missed medication doses led to the resident's hospitalization due to exacerbated psychosis symptoms.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide appropriate care and treatment for three residents, leading to deficiencies in their care. One resident with Parkinson's disease and a deep brain stimulator (DBS) did not receive proper device management. The staff failed to apply or charge the DBS as ordered, and the resident was observed without the charging neck sling on multiple occasions. The facility's staff, including the Nursing Home Administrator and Director of Nursing, were unaware of the DBS's remote control function, and there was no evidence of staff education on the device's use. This lack of proper management could exacerbate the resident's Parkinson's symptoms. Another resident with dementia and a history of intimate relationships experienced a significant change in condition, including a decline in cognitive function. Despite this, the facility did not update the resident's intimacy assessment or care plan to reflect the change. The resident's interactions with another resident were not adequately monitored, and staff were unclear about the appropriate actions to take. The facility's policy required reassessment of consent capacity with any condition changes, but this was not followed, leading to confusion and potential issues with consent. A third resident with a diagnosis of fungal candidiasis did not receive oral care as outlined in their care plan. The care plan specified the use of a toothette with toothpaste and mouthwash, but staff only used water for oral care. This deviation from the care plan raised concerns about the effectiveness of the treatment for the resident's recurring thrush. The Director of Nursing was unaware that the care plan was not being followed, indicating a lack of oversight and communication within the facility.
Deficiencies in Resident Safety and Staff Training
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, leading to a fall incident involving a resident. The resident, who had a history of cerebral infarction, polyneuropathy, and hemiplegia, was assessed to require a full body (Hoyer) lift with the assistance of two staff members for transfers. However, on the day of the incident, a CNA did not adhere to the care plan and attempted to transfer the resident using a sit-to-stand lift, resulting in the resident feeling weak and subsequently falling. The facility's fall policy mandates that all residents receive adequate supervision and assistance to prevent falls, but this was not followed in this case. Additionally, the facility did not provide timely staff education on safe transfer techniques. Although transfer education was conducted, the attendance record showed that 15 CNAs did not receive the training initially. The Nursing Home Administrator confirmed that the Director of Nursing was still working on completing the staff education related to safe transfers and adherence to care plans. This lack of comprehensive training contributed to the unsafe transfer practices that led to the resident's fall. Furthermore, the facility was found to have safety hazards related to the charging of motorized wheelchair batteries in a vacant resident room. The room lacked proper ventilation and was used for storage, including flammable materials, without a door closure. The chargers used for the batteries had warnings about explosive gases and the need for adequate ventilation, which was not provided. This created a potential fire hazard, as confirmed by the Life Safety Consultant, who noted the absence of ventilation and the need for a door closer due to the storage of boxes in the room.
Medication Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure accurate administration of medication for two residents, R4 and R10, as identified during a survey. R4 received multiple scheduled medications late over several days in December 2024 and January 2025. These medications included Vitamin C, Apixaban, Duloxetine, Guaifenesin, Lactobacillus Probiotic, Magnesium Oxide, Metformin, Norethindrone Acetate, Sulfamethoxazole-Trimethoprim, Ropinirole, Metoprolol Tartrate, Buspirone, Ursodiol, Gabapentin, Topiramate, and Gabapentin Capsule. The Director of Nursing confirmed that the facility's policy allows for medication administration within one hour before or after the scheduled time, and acknowledged that the medications were administered outside this timeframe. R10 experienced a failure in receiving scheduled pain medication on the night shift of January 13, 2025. Despite having a physician's order for Tramadol to be administered every six hours, R10 did not receive the midnight dose, resulting in increased pain levels. The Assistant Director of Nursing confirmed that the dose was not administered because it was deemed too close to the next scheduled dose. R10 expressed frustration over the lack of timely pain management and reported that staff were overworked, leading to communication breakdowns regarding medication needs. Additionally, R10's medications were left unsupervised by LPN-L, who did not ensure that R10 took the medication. This occurred despite R10 not having a self-administration assessment or order. R10 expressed concerns about the potential for medication misuse, as nurses would leave medication without observing its consumption. The Nursing Home Administrator confirmed that R10 should not have been left with medication unsupervised, as there was no assessment or order permitting self-administration.
Failure to Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act, for one resident. On a specific date, a Certified Nursing Assistant (CNA) reported an allegation of verbal abuse involving another CNA and a resident with severe cognitive impairment. The resident had a history of unspecified intracranial injury with loss of consciousness and nontraumatic subarachnoid hemorrhage. Despite the report of abuse being made to the administration and an investigation being initiated, the facility did not report the allegation to local law enforcement as required by their policy. The facility's undated Abuse policy mandates contacting local law enforcement when there is a reasonable suspicion of a crime. However, in this case, the Nursing Home Administrator did not notify law enforcement, despite typically doing so for abuse allegations. The incident involved a CNA allegedly using abusive language towards a resident, which was witnessed by another CNA. The accused CNA was suspended and later returned to work after completing education on abuse, effective communication, and managing difficult behaviors. The failure to report the incident to law enforcement was noted as a deficiency during the surveyor's review.
Failure to Respond to Resident's Change of Condition
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident, R2, who experienced a significant change in condition. On 5/16/24, R2 reported difficulty breathing and feeling like they were having a stroke. Despite these serious symptoms, the nursing staff, including RN-C and LPN-K, did not adequately assess R2 or report the concerns to a physician. Additionally, the change in condition was not communicated to the night shift staff, leading to a lack of continuous monitoring and care. R2 had a history of chronic respiratory failure, hypertension, and anxiety, among other conditions, and was known to have increased anxiety when unable to clear secretions from their trach. On the morning of 5/16/24, CNA-D noticed R2 was incontinent, pale, and weaker than usual, and reported these observations to RN-C multiple times. However, RN-C did not respond appropriately, and there was no documentation of any assessment or vital signs after 5/15/24. Other staff members, including CNA-J and LPN-K, also noted R2's distress but failed to take adequate action. The lack of proper assessment and communication resulted in R2's condition deteriorating without appropriate medical intervention. R2 was found unresponsive and pronounced dead on 5/17/24 due to diastolic congestive heart failure. The facility's failure to adhere to the Wisconsin Nurse Practice Act and its own policies on change of condition led to a finding of immediate jeopardy, highlighting the serious nature of the deficiency.
Removal Plan
- Educate nursing staff on change of condition policies and procedures, how to conduct a physical head-to-toe assessment, completing change of condition documentation, family and provider notification, and a change of condition form.
- Initiate monitoring of nursing and CNA shift-to-shift reports.
- Complete a change of condition audit and initiate shift change audits.
- Hold a quality assurance performance improvement (QAPI) meeting with the Medical Director to discuss the event and corrective measures to be taken.
Incompetent Staff Assigned to Resident Care Tasks
Penalty
Summary
The facility failed to ensure that competent staff performed nail care for a resident, identified as R3, who was part of a sample of nine residents. R3 had a history of aneurysm, anxiety, malnutrition, depression, and dementia, and was prescribed warfarin sodium, an anticoagulant medication. Despite these conditions, Hospitality Aide (HA)-E, who was not a certified nurse aide, was asked by Registered Nurse (RN)-C to trim R3's nails. HA-E confirmed performing the task but ceased after realizing the lack of qualification for such duties. The Director of Nursing (DON)-B confirmed that HAs were not supposed to trim residents' nails. Additionally, the facility did not ensure that competent staff completed vital signs for multiple residents. HA-E and HA-L, who were not enrolled in a Certified Nursing Assistant (CNA) course, were asked by RN-C to take vital signs. HA-E expressed confusion about this task, as HA-E had no CNA training. Interviews with other staff, including CNA-D, RN-H, and CNA-I, revealed inconsistencies in the delegation of vital signs, with some staff indicating that only CNAs should take regular vital signs, while others noted that HAs were improperly tasked with this responsibility. The surveyor's review of HA sign-off sheets for vital signs showed that HA-L and HA-E were signed off by RN-C, but both required more training, particularly in manual blood pressures. No follow-up or re-evaluation was conducted. The DON-B acknowledged that RN-C had been reprimanded for not documenting proper assessments and had been written up for similar concerns. This lack of proper training and oversight led to the deficiency in ensuring competent staff performed necessary resident care tasks.
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Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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