Avina On 32nd
Inspection history, citations, penalties and survey trends for this long-term care facility in Kenosha, Wisconsin.
- Location
- 8633 32nd Ave, Kenosha, Wisconsin 53142
- CMS Provider Number
- 525282
- Inspections on file
- 33
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Avina On 32nd during CMS and state inspections, most recent first.
Several residents requested a grievance box and accessible grievance forms to allow for anonymous complaints, but only an unlocked suggestion box was provided and grievance forms were not available at the nurses' station. Staff were unaware of the location of grievance forms, and the facility's grievance policy was locked away, making it inaccessible to residents. This resulted in residents lacking a means to file grievances anonymously or without staff knowledge.
A resident with hemiplegia and intact cognition reported her antenna was stolen from outside her room while she was napping. Another resident witnessed a staff member cut the wires and take the antenna. The incident was reported to the Administrator, but the antenna was not replaced and the investigation was incomplete. The facility failed to report the misappropriation to the state as required by policy.
A resident with cognitive intactness and physical impairment reported that her antenna was stolen from outside her room while she was napping, with another resident witnessing a staff member taking the item. The incident was reported to the Administrator, but the allegation was not reported to state authorities as required, and the investigation file was incomplete. The facility's policy mandates reporting such incidents, but this was not followed.
Thirteen residents experienced misappropriation of their trust funds when a staff member manipulated account transactions for personal gain. The staff member concealed unauthorized withdrawals, making them appear legitimate and bypassing existing oversight procedures. Despite the discrepancies, residents did not report issues accessing their funds, and no negative outcomes were reported during interviews.
The facility failed to ensure a safe environment for residents who smoke or vape, and for a resident requiring assistance during transfers. Thirteen residents were allowed to smoke or vape without proper supervision or safety measures. One resident vaped in her room while using oxygen, posing a fire risk. Another cognitively impaired resident smoked unsupervised outside designated areas. Additionally, a resident was left outside in the cold after smoking, unable to re-enter the building independently. A resident requiring a Hoyer lift was transferred by a CNA without a second staff member, resulting in bilateral femoral fractures.
The facility failed to properly label and date food items, leading to potential food safety issues for 51 residents. Observations revealed expired heavy whipping cream, incorrectly dated food containers, and improperly managed thickened drinks and shakes. The dietary manager was unaware of specific requirements for dating thawed and opened items, resulting in potential risks of food-borne illness.
The facility failed to maintain a safe and homelike environment, with six resident rooms showing various forms of wall damage, including unpainted drywall, holes, and broken areas. Staff, including the NHA and Maintenance Director, were aware of the issues but cited a lack of time to address them. The facility's policy lacked specific procedures for room upkeep.
A resident with severe cognitive impairment was not assessed or authorized for self-administration of medications, contrary to facility policy. Medications were left at the resident's bedside without proper identification or a physician's order, increasing the risk of medication errors. The DON confirmed that the resident could not self-administer medications.
A resident with a history of cystocele repair and a suprapubic catheter was admitted to a facility without an indication for the catheter and without physician orders for catheter care. The care plan did not include the appropriate catheter type, and the catheter bag lacked a privacy cover. Observations and interviews confirmed these deficiencies, indicating a failure to comply with proper catheter care protocols.
Two residents experienced delays in receiving pain medication, with one resident waiting over 30 minutes and another over an hour. The delays were due to staff being occupied with other tasks, leading to increased pain levels for both residents.
A resident with diabetes mellitus received improperly mixed Novolog 70/30 insulin from a Certified Medication Technician (CMT) who was unaware of the need to mix the insulin before administration. The Director of Nursing confirmed the oversight, which could have affected the resident's blood glucose levels.
The facility failed to follow proper infection control practices, leading to potential cross-contamination during care for two residents. CNAs did not wear gowns for a resident with enhanced barrier precautions, and a CNA used the same gloves for multiple tasks during catheter care. An RN did not sanitize a table before a dressing change, and another RN dispensed medications without hand hygiene or gloves, contaminating the tablets.
A resident with pressure ulcers and a leg fracture did not receive proper care due to the facility's failure to update the care plan. The resident's leg brace was not discontinued as ordered, and heel boots for pressure relief were not used. Staff continued to document skin checks under a brace that was no longer worn, and the care plan was not updated to reflect these changes.
Two residents requiring Enhanced Barrier Precautions (EBP) due to wounds and indwelling catheters did not receive appropriate care. Observations showed a lack of signage and personal protective equipment (PPE) near their rooms, and staff did not wear gowns during wound care treatments, violating EBP protocols. The Director of Nursing confirmed the need for EBP, but staff failed to comply.
Failure to Provide Accessible Grievance Process for Residents
Penalty
Summary
The facility failed to support residents' rights to voice grievances or complaints without discrimination or reprisal. During a resident group interview, several alert and oriented residents stated that they had requested the installation of a grievance box with attached grievance forms to allow for anonymous submissions. Review of Resident Council minutes confirmed repeated requests for accessible grievance forms and a grievance box, with the administrator initially agreeing to provide these. However, observations revealed that only an unlocked suggestion box was available, not a grievance box, and that the suggestion cards did not serve the same purpose as grievance forms. The facility's grievance policy and procedure were found locked in a glass cabinet, making them inaccessible to residents, and no grievance forms were readily available at the nurses' station as claimed by the administrator. Interviews with staff, including a registered nurse and the social service director, indicated that grievance forms were not present at the nurses' station and staff were unaware of their location. The Resident Council President confirmed ongoing requests for a grievance box and forms, emphasizing that residents should not have to ask staff for these materials. The facility's own grievance policy stated that notices of residents' rights regarding grievances should be posted in prominent locations and that grievance forms should be accessible, but these requirements were not met, resulting in a failure to provide residents with a means to file grievances anonymously or without staff knowledge.
Failure to Prevent and Report Misappropriation of Resident Property
Penalty
Summary
A cognitively intact resident with a diagnosis of flaccid hemiplegia reported that her antenna, which was magnetically mounted outside her room, was stolen while she was napping. Another resident stated that they witnessed a staff member, identified as the Wound Care Nurse/PM Supervisor, cut the wires and take the antenna. The resident reported the missing antenna to the Administrator, who indicated he would replace it, but the antenna was not replaced. The Administrator later discovered that the replacement order had been cancelled by Corporate, and the whereabouts of the original antenna remained unknown. The facility's investigation into the misappropriation of property was incomplete, and the incident was not reported to the State of Wisconsin as required by facility policy. The accused staff member denied involvement, stating they were not present at the facility when the incident occurred. The facility's policy mandates reporting allegations or suspicions of misappropriation to the state survey agency, but this was not followed in this case.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property involving a resident who was cognitively intact and had a diagnosis of flaccid hemiplegia affecting the left nondominant side. The resident reported that an antenna, which was magnetically mounted outside her room, was stolen while she was napping. Another resident witnessed a staff member, identified as the Wound Care Nurse/PM Supervisor, cut the wires and take the antenna. The resident reported the missing antenna to the Administrator, who stated he would replace it, but the antenna was not replaced, and the resident remained without it. Upon review, it was found that the Administrator was informed of the allegation but did not report the incident to the State of Wisconsin as required. The Administrator also acknowledged that the investigation file was incomplete and was unaware that the replacement order for the antenna had been canceled by Corporate until the issue was raised during the complaint survey. The accused staff member denied involvement, stating she was not present at the facility when the incident occurred. The facility's policy requires reporting of suspected abuse, neglect, or misappropriation to state authorities, but this protocol was not followed in this case.
Misappropriation of Resident Trust Funds by Staff Member
Penalty
Summary
The facility failed to protect the belongings and funds of thirteen residents, resulting in misappropriation of resident trust funds by a former Business Office Manager (FBOM). The FBOM was found to have taken monies from the resident trust for personal gain, with discrepancies identified in the accounts of multiple residents. The incident was discovered after suspicions arose regarding unauthorized use of the facility credit card, prompting an internal investigation and audit of the resident trust fund, facility credit card, and petty cash accounts. The audit revealed that the FBOM had manipulated transactions to appear legitimate, making the misappropriation difficult to detect. Interviews with facility leadership confirmed that the FBOM had a clean background check and no prior indications of misconduct. The FBOM was able to conceal the movement of funds and falsify documentation, which allowed the misappropriation to go unnoticed during routine oversight. Despite the discrepancies, residents did not report issues with accessing their funds when requested, and no negative outcomes were voiced by residents during interviews conducted as part of the survey process. A review of facility policies indicated that procedures were in place to safeguard resident funds, including requirements for documentation, witness signatures for disbursements, and monthly transaction reviews. However, these controls were insufficient to prevent the FBOM from accessing and misappropriating resident funds. The deficiency was identified through the facility's own investigation and subsequent audit, which flagged irregularities in the trust accounts of thirteen residents.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for residents who smoke or vape, as well as for a resident requiring assistance during transfers. Thirteen residents were identified as being allowed to smoke or vape without proper supervision or safety measures in place. One resident was observed vaping in her room while using oxygen, which poses a significant fire risk. Another resident, who was severely cognitively impaired, was allowed to smoke unsupervised outside of designated areas without any safety equipment present. Additionally, a resident was left outside in the cold for an extended period because he could not re-enter the building independently after smoking. The facility's policies on smoking and vaping were not adequately enforced, as evidenced by the lack of initial and quarterly smoking assessments for several residents. Care plans for residents who smoked or vaped were not consistently developed or updated to reflect their needs and safety requirements. This lack of oversight and documentation contributed to the unsafe conditions observed by surveyors. Furthermore, a resident who required a Hoyer lift for transfers was moved by a CNA without the assistance of a second staff member, resulting in the resident sustaining bilateral femoral fractures. The CNA admitted to transferring the resident alone, which violated the facility's resident handling policy. This incident highlights the facility's failure to provide adequate supervision and assistance during resident transfers, leading to actual harm.
Removal Plan
- The facility updated their policy and procedure to address safety in using e-cigarettes including their use only in designated smoking areas.
- Assessments were reviewed and updated for all residents known to smoke/vape.
- Care plans were reviewed and updated for all residents known to smoke/vape. Appropriate interventions were put into place to ensure resident safety.
- All staff were trained on the updated policy and procedure and location of the smoking area.
Food Labeling and Dating Deficiency in Facility Kitchen
Penalty
Summary
The facility failed to ensure that food items were properly labeled and dated, leading to potential food safety issues for 51 residents who received meals from the facility kitchen. During an initial kitchen observation, it was found that the walk-in refrigerator contained six one-quart cartons of heavy whipping cream with expired dates. The dietary aide confirmed the expired dates and stated they would be discarded. Additionally, three large plastic containers in the food preparation area had incorrect or uncertain posted dates for breadcrumbs, oatmeal, and rice. The dietary manager could not confirm when these items were placed in the containers. A 25 lb. container of Ready Care Instant Food Thickener was found opened and uncovered, with an old date, and the dietary manager acknowledged it had not been used for a long time and needed to be discarded. Further observations revealed that the walk-in refrigerator contained a box of Ready Care Strawberry Shakes that were thawed but not dated, contrary to instructions to use within 14 days after thawing. The dietary manager was unaware of the requirement to date the shakes when thawed. Additionally, opened cartons of Ready Care Thickened Dairy Drink and Ready Care Thickened Apple Juice were found with dates exceeding the recommended 7-day refrigeration period after opening. The dietary manager was not aware of the special requirements for these thickened drinks and disposed of the opened drinks. These lapses in food labeling and dating practices had the potential to lead to food-borne illness among all facility residents.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe and homelike environment for residents, as evidenced by the condition of six resident rooms across two halls. Observations revealed various forms of wall damage, including unpainted drywall plaster, holes, and broken areas in the walls. In one room, a resident expressed a desire for the unpainted area behind their bed to be painted, indicating a lack of timely maintenance. Additionally, a curtain rod was found to be broken, further contributing to the unsafe and unhomelike conditions. Interviews with staff, including the Nursing Home Administrator and the Maintenance Director, confirmed awareness of the room conditions. The Maintenance Director admitted to receiving notifications about the wall damage but cited a lack of time to address all issues. The facility's policy on maintaining a safe and homelike environment lacked specific procedures for room upkeep, contributing to the ongoing deficiencies in room maintenance.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R3, was properly assessed and authorized for self-administration of medications. R3, who was admitted with a diagnosis of dementia, was found to have a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. Despite this, there was no evidence in R3's medical record of a physician's order for self-administration of medication, nor was there an assessment or care plan in place for self-administration. This oversight was contrary to the facility's policy, which requires an interdisciplinary team assessment and a prescriber's order for residents who wish to self-administer medications. During an initial tour, a medication cup containing various pills was observed on R3's overbed table. R3 was unable to identify the medications or recall who provided them. A Certified Medication Tech (CMT) confirmed that she had given the medications to R3, but they were left on the overbed table, and she could not identify them. The Director of Nursing (DON) confirmed that medications should not be left at a resident's bedside unless the resident is capable of self-administration, which R3 was not. This failure to adhere to the facility's policy increased the potential for medication errors.
Inadequate Catheter Care for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic catheter. The resident, who had a history of cystocele repair and a suprapubic catheter, was admitted to the facility without an indication for the catheter and without physician orders for catheter care. The resident's care plan did not include the appropriate type of catheter, and there was no documented evidence of catheter care as an intervention. Observations revealed that the resident's catheter bag lacked a privacy cover and was positioned in a way that was visible to others. Interviews with the Director of Nursing confirmed the absence of necessary physician orders, an indication for the catheter, and the correct catheter type in the care plan. The DON also confirmed that the catheter bag should have had a privacy cover, which was not initially provided. These deficiencies were identified through observations, interviews, and record reviews, highlighting a lack of compliance with proper catheter care protocols for the resident.
Delayed Pain Management for Two Residents
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents, R42 and R149, as per their care plans and professional standards. R42, who was admitted with conditions including peripheral vascular disease and a surgical wound, reported a pain level of 6.5 out of 10, which she considered unacceptable. Despite requesting pain medication, there was a delay of over 30 minutes before she received it. During this time, R42 was observed moaning and rocking due to pain. The LPN responsible for administering the medication was observed engaging in other tasks and delayed attending to R42's request. R149, who had an abdominal surgical wound, also experienced significant delays in receiving pain medication. She reported pain levels of 8 or 9 out of 10 and had to wait over an hour for her medication after requesting it. The delay was attributed to the assigned nurse, RN J, being tasked with one-on-one supervision duties in another unit, which disrupted her medication pass schedule. As a result, R149's pain level increased to 10 out of 10 before she received her medication. Interviews with the Director of Nursing and other staff confirmed that the delays in administering pain medication were not in line with the facility's policy and expectations. The DON acknowledged the importance of timely pain management and was unaware of the specific delays experienced by R149. The facility's policy emphasized prompt assessment and treatment of pain, which was not adhered to in these cases.
Failure to Properly Mix Insulin Before Administration
Penalty
Summary
The facility failed to ensure that medications were accurately administered to a resident, identified as R9, who was readmitted with a diagnosis of diabetes mellitus. During an observation, a Certified Medication Technician (CMT M) prepared and administered Novolog 70/30 insulin to R9 without mixing it as required. The manufacturer's instructions for Novolog 70/30 insulin specify that the vial should be gently rolled to mix the 70% intermediate-acting insulin with the 30% short-acting insulin before administration. However, CMT M did not perform this step, which could lead to an inaccurate dosage being administered. Interviews conducted with CMT M and the Director of Nursing (DON B) confirmed the oversight. CMT M admitted to not being aware of the need to mix the insulin, despite having been marked as satisfactorily performing insulin administration on her competency checklist. DON B acknowledged that the failure to mix the insulin could have affected R9's blood glucose levels. An interview with a Registered Nurse (RN N) further confirmed the correct procedure for preparing 70/30 insulin, which involves rolling the vial to mix the two types of insulin.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, resulting in potential cross-contamination during care for two residents. Resident R35, who had enhanced barrier precautions due to a previous infection with Providencia Rettgeri, did not receive appropriate care as CNAs F and G provided personal care without wearing gowns, despite being aware of the need for enhanced precautions. Additionally, CNA D, while providing suprapubic catheter care for Resident R100, failed to change gloves after touching various surfaces and carried soiled towels against his uniform, which could have led to contamination. Further deficiencies were observed during a wound dressing change for Resident R100, where RN E did not sanitize the overbed table or use a barrier before placing dressing supplies on it. Additionally, RN N dispensed medications for another resident without performing hand hygiene or wearing gloves, using her fingers to take tablets from bottles, which contaminated the medications. The Director of Nursing confirmed these lapses in infection control procedures, acknowledging the risk of cross-contamination and infection to other residents.
Failure to Update Care Plan and Provide Pressure Relief
Penalty
Summary
The facility failed to ensure that a resident with pressure injuries received the necessary care and treatment to promote healing. The resident was admitted with unstageable pressure ulcers on the left thigh and shin, as well as a leg brace for a fracture. The facility did not update the resident's care plan to reflect the discontinuation of the leg brace as ordered by the orthopedic physician, nor did it include the use of heel boots for pressure relief. The resident's care plan and CNA Kardex were not updated after the orthopedic physician's order to discontinue the leg brace. Despite the order, staff continued to document skin checks under the brace, which the resident was no longer wearing. Additionally, during a wound treatment observation, the resident was not offered heel boots, which were supposed to be used at all times for pressure relief. Interviews with the Wound RN and the Director of Nursing confirmed that the care plan should have been updated to reflect the discontinuation of the leg brace and the use of heel boots. The facility's failure to update the care plan and ensure the use of heel boots resulted in inadequate care for the resident's pressure ulcers.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, R1 and R2, as recommended by the CDC and per the facility's policy. R1 was admitted with multiple diagnoses, including unstageable pressure ulcers and an indwelling catheter, which required EBP. However, observations revealed that there was no sign posted on R1's door to indicate the need for EBP, and there were no gloves or gowns available near the room. During wound care treatment, the staff did not wear gowns, violating the EBP protocol. Similarly, R2, who had severe cognitive impairment and multiple wounds, including an unstageable pressure ulcer and an indwelling catheter, also required EBP. Observations showed that there were no indications of EBP in R2's room. During wound care treatment, the staff used gloves and hand hygiene but did not wear gowns, failing to adhere to the EBP guidelines. Interviews with the Director of Nursing confirmed that both residents should have been on EBP due to their conditions. Despite being aware of the policy, the staff did not follow the required precautions, and no additional information was provided to explain the non-compliance.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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