Beaver Dam Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Beaver Dam, Wisconsin.
- Location
- 410 Roedl Ct, Beaver Dam, Wisconsin 53916
- CMS Provider Number
- 525338
- Inspections on file
- 37
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 11 (2 serious)
Citation history
Health deficiencies cited at Beaver Dam Health Care Center during CMS and state inspections, most recent first.
A resident with multiple mental health and behavioral diagnoses, who was cognitively intact and allowed to safeguard her own smoking materials, used a personal lighter to ignite cut-up ace wrap and sheet pieces on her room floor, admitting to staff that she started the fire on purpose. Staff found a burned, wet pile in the room and reported also locating a knife and medications among her belongings, which were given to the administrator. Although the facility’s smoking policy required secure storage of all smoking materials, prohibited such items in resident rooms, and mandated smoking safety reassessments with any change in condition, the facility did not promptly complete an updated smoking safety assessment after the fire and continued to care plan the resident as managing her own smoking materials, with staff reporting she still went in and out to smoke and used a lockbox in her room. A later smoking assessment, completed only after surveyor inquiry, did not document the prior fire or identify concerns, leading surveyors to cite a deficiency for failure to reassess and implement appropriate safety measures regarding smoking materials.
A resident with multiple behavioral health and medical diagnoses was allowed to keep and use a backpack of medications in their room without the facility completing the required interdisciplinary assessment and care plan for self-administration. Nursing staff, including LPNs, reported that the resident would not allow them to inspect the backpack and they were unaware of the specific medications being taken. Later review revealed the resident possessed several prescription and over-the-counter drugs and supplements, but at the time of the survey there was no documented self-administration assessment in place, contrary to facility policy requiring evaluation of cognitive, physical, and visual abilities and an IDT determination before permitting self-administration.
The deficiency centers on the facility’s failure to control smoking materials and supervise unsafe smoking behaviors, particularly for a resident with COPD and chronic hypoxic respiratory failure who used oxygen. Staff documented that this resident, who had not smoked for years, recently began smoking heavily, was repeatedly observed smoking in non-designated areas, including inside the building and at the main entrance, and was twice found smoking in his room while oxygen was in use, once putting a cigarette out on window drapes. Despite these events and a facility policy requiring a safe smoking assessment, care plan interventions, and nursing control of smoking materials, no smoking assessment or smoking care plan was completed for this resident, and oxygen orders referenced in physician notes were not on the MAR/TAR. In a separate incident, two residents were seen exchanging a lighter in a hallway while an LPN remained at the nurse station and stated residents could keep their own smoking materials, conflicting with the DON’s statement that materials should be returned to staff and not passed between residents.
A resident with multiple comorbidities and wounds had an H&P order for close monitoring of fluid status and an RD-established daily fluid goal, but staff did not consistently track or respond to low fluid intakes. Over multiple extended periods, the resident frequently failed to meet estimated fluid needs, yet the RD and provider were not notified, and no documented hydration assessments or new interventions were implemented. The resident experienced repeated episodes of altered mental status and signs of dehydration, was sent to the ED/hospital three times, and received multiple liters of IV fluids for dehydration, while ED instructions to provide electrolyte drinks and ensure adequate oral fluids were not reflected in the record. The DON later acknowledged that expected 72-hour post-hospital assessments and monitoring were not documented, demonstrating a systemic failure to monitor and manage hydration.
Surveyors found that multiple CNAs did not have documentation of the required 12 hours of annual in‑service training, despite facility policy requiring at least 12 hours per year and maintenance of records in personnel files. Review of five CNAs’ 2025 education records showed one CNA with only 10 documented hours and four CNAs with only 1 documented hour each, and several Nurse Aide Competency Forms lacked any notation of credited in‑service hours. The NHA reported that the facility had lost access to its computerized education system and had transitioned to in‑person in‑services, and acknowledged that there was no documentation showing that these CNAs had received the required annual training, potentially affecting all residents.
The facility failed to maintain an effective pest control program for bed bugs, as multiple staff and cognitively intact residents reported seeing bed bugs in several rooms, and one resident had documented red, itchy, bug bite-like lesions on her arms, back, and neck. Staff described capturing a suspected bed bug in a sealed container, stripping beds, and deep cleaning rooms after sightings in the rooms of two residents, while another room had a recent reported sighting with photos sent to the Director of Maintenance. The Director of Maintenance admitted that bed bugs periodically appeared and that he used a Gentrol mixture for at least three treatments over an extended period, despite manufacturer instructions to use the diluted solution within 48 hours, and he did not know the product’s purchase or expiration date. The NHA stated he was unaware the chemicals were donated from an outside job years earlier and had instructed the Director of Maintenance to use these facility-held chemicals instead of calling an exterminator.
The facility failed to thoroughly investigate and timely report multiple resident-to-resident altercations and threats, contrary to its abuse/neglect policies and state requirements. In one event, a resident with dementia and moderate cognitive impairment slapped another cognitively impaired resident in the dining room; the facility’s investigation summary claimed all staff on duty were interviewed and skin checks were completed on all residents on the unit, but there was no documentation of these interviews or additional skin assessments, and only staff who directly witnessed the incident were actually interviewed. In another series of events, a cognitively impaired resident with a history of aggression threatened and later struck a cognitively intact resident; although the facility’s reports stated that comprehensive investigations with staff and resident interviews were conducted, the investigation file contained either no interviews or only one staff interview. For both incidents, the required five-day follow-up reports to the state agency were submitted late, and leadership acknowledged that not all relevant staff and residents were interviewed and that key investigative steps were undocumented or not completed.
Two residents received oxygen and non-invasive ventilation without corresponding physician orders or MAR/TAR documentation, contrary to facility policy requiring ordered, care-planned oxygen therapy with specified equipment settings and monitoring. One resident with COPD and chronic hypoxic respiratory failure had physician notes indicating a need for long-term oxygen and specific saturation goals, yet no oxygen orders were present while oxygen equipment was in the room and in use, including during smoking episodes. Another resident with muscle wasting, morbid obesity, and obstructive sleep apnea was reported by the ADON and an LPN to use BiPAP/CPAP with oxygen at night, but no orders for oxygen or BiPAP/CPAP were found in the physician orders or MAR/TAR when requested by surveyors.
A facility failed to ensure that a Medication Assistant (MA), who is also a CNA, received the required 4 hours of annual medication-based in-service training. The MA’s 2025 education record showed only 1 hour of in-service, split between QAPI and Compliance/Ethics, with no medication-related content documented. A signed medication administration education form did not list any credited in-service hours. In an interview, the NHA confirmed that MAs are required to complete 4 hours of medication-related education annually and acknowledged there was no documentation that this MA had received the required training.
Three residents did not receive necessary care as ordered, including missed wound care treatments and lack of daily assessments during IV antibiotic therapy. Missed treatments were not consistently communicated to the physician, and there was no documentation that residents were educated about the risks and benefits of missing care. Facility policies requiring documentation, physician notification, and resident education were not followed.
A resident with polyneuropathy was prescribed Gabapentin to be given every 8 hours upon admission, but facility staff entered the order as twice daily instead of three times daily. Interviews with the NP, UM, and DON confirmed the error and that the facility's policy was not followed, resulting in a medication administration deficiency.
Two residents experienced verbal abuse, belittlement, and neglect by a CNA, including yelling, mocking, and withholding of care, resulting in fear, anxiety, and physical discomfort. Staff and administration were aware of the concerns but failed to report or address the abuse, leaving the residents unprotected and distressed.
The facility did not ensure that allegations of abuse and mistreatment involving two residents were reported to the appropriate authorities within the required timeframe. Staff and residents reported incidents of verbal and psychological abuse by a CNA, but these were not consistently reported or investigated as required by policy. The nursing home administrator failed to treat all allegations seriously, and the facility did not foster an environment where concerns could be freely reported.
A resident with a G-Tube placed for dysphagia after a stroke did not receive the ordered care to maintain tube patency, as the required flushes and monitoring were not transcribed or implemented for several months. Staff reported that no interventions were provided for the G-Tube, and observations revealed drainage at the site. Facility leadership acknowledged that a care plan and physician orders for G-Tube care should have been in place, but were not followed.
A resident with multiple chronic conditions and severe pain did not receive all prescribed pain medications due to pharmacy and insurance delays, and staff did not implement non-pharmacological interventions as outlined in the care plan. The resident consistently reported high pain levels, and staff interviews confirmed delays in response and lack of alternative pain management approaches.
A resident at high risk for pressure injuries developed multiple stage 3 and stage 2 pressure injuries due to inadequate care and prevention measures. The facility failed to update the care plan with physician recommendations for frequent repositioning and did not transfer the resident to a functioning surface during a power interruption, leaving them on a deflating air mattress. Other residents were similarly affected by the power issue, highlighting the facility's failure to provide consistent and adequate pressure ulcer care.
The facility failed to adhere to professional standards for food service safety, affecting all 68 residents. Surveyors found unlabeled and uncovered food items in the kitchen and kitchenette, including expired items. The kitchenette microwave was also found with dried-on splatters, indicating poor cleaning practices. Interviews revealed uncertainty about responsibilities for food labeling and cleaning.
The facility's infection prevention and control program is inadequate, with incomplete staff and resident surveillance line lists lacking specific symptoms, infection types, and precaution details. The ADON/IP acknowledged these deficiencies and indicated recent efforts to improve documentation.
The facility failed to provide effective emergency preparedness training for staff, resulting in confusion during a power outage. Staff were unable to locate emergency outlets, and residents experienced discomfort due to deflating air mattresses. The DON acknowledged the need for training, which had not been conducted.
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by multiple observations and complaints. Residents reported unclean rooms, with surveyors noting dust, debris, and unclean floors. The facility was short-staffed in housekeeping, contributing to the deficiency.
The facility failed to maintain a safe environment by charging a motorized wheelchair in the dining room and improperly storing a resident's oxygen tank. Staff were unaware of safety protocols, leading to potential hazards for residents, including one with COPD and diabetes requiring continuous oxygen therapy.
The facility failed to label insulin vials according to professional standards, with four residents having undated open insulin pens. Additionally, medication carts were left unlocked and unsupervised, with medications accessible to others. Staff interviews confirmed the expectation for proper labeling and securing of medications, highlighting lapses in adherence to protocols.
The facility failed to offer pneumococcal vaccines to four residents as per CDC recommendations and facility policy. Despite having a policy in place, the residents were not provided with the necessary immunizations, and there was no documentation of consent or declination. The Infection Preventionist confirmed the oversight, acknowledging that the vaccines should have been offered.
A resident with hypothyroidism and other conditions was observed taking her thyroid medication left at her bedside, contrary to the facility's policy. The facility's policy requires an interdisciplinary team assessment for self-administration, which was not conducted for this resident. Staff confirmed that the resident was not permitted to self-administer medications, indicating a failure in the medication administration process.
The facility failed to provide comprehensive care plans for two residents, one receiving Melatonin without a sleep assessment or tracking, and another with a feeding tube lacking a care plan for tube care. The DON acknowledged the oversight in both cases.
A resident with legal blindness and mild cognitive impairment was not provided with activities that matched their interests, such as listening to news and music. The facility failed to document activities offered or ensure the resident's care plan reflected their preferences. Observations showed the resident spent long periods in front of a television without engagement, and staff interviews revealed a lack of personalized activity planning.
A resident with significant cognitive impairment experienced an unwitnessed fall resulting in a head injury, but the facility failed to initiate neurological checks as required by their policy. The resident was found with a bruise on her forehead and hand, yet continued monitoring was not conducted. The DON acknowledged the oversight, and the NHA expected adherence to the fall policy, especially with evidence of a head injury.
The facility failed to maintain proper catheter care for two residents, as their catheter bags were observed in direct contact with the floor, contrary to infection control guidelines. Despite staff acknowledging the importance of keeping catheter bags off the floor, the surveyor noted repeated lapses, posing a risk of urinary tract infections.
A resident was observed self-administering levothyroxine at 11:17 AM, despite it being scheduled for 6 AM. The facility's policy requires medications to be administered by authorized personnel and within 60 minutes of the scheduled time. Interviews with staff revealed that the resident was not authorized to self-administer medications, except for an inhaler, and that medications should not be left at the bedside, indicating a failure in the facility's medication administration process.
The facility failed to follow its antibiotic stewardship program for two residents treated for UTIs without proper documentation of C&S testing. One resident was admitted from an ED with a UTI diagnosis and orders for Cephalexin, but the facility lacked necessary documentation to support the treatment. Another resident was treated without appropriate indication, lacking UA and C&S documentation. The facility's policies on antibiotic stewardship and infection surveillance were not followed, leading to the deficiency.
A resident did not receive two doses of a scheduled intravenous antibiotic and had multiple medication orders transcribed incorrectly, leading to missed doses of essential medications. The facility's failure to notify the physician and clarify medication orders resulted in the resident experiencing increased pain and sleep disturbances.
The Bedrock Corporation failed to maintain current payments with several service providers, leading to service disruptions and discontinuation notices. The facility's pharmacy provider was terminated, and significant amounts are owed to vendors like Sysco, Synapse Health, and Point Click Care. The corporation also owes CMS for Civil Money Penalties and has a bed tax assessment due. The facility owner acknowledged the issues and stated efforts are being made to pay the bills, but the lack of timely payments has resulted in potential service disruptions and negatively impacts resident care.
A resident did not receive prescribed Nystatin suspension for several days due to the facility's failure to follow its medication reordering policy. The resident, who was cognitively intact and had a fungal infection, experienced discomfort and visible symptoms. The facility did not communicate with the pharmacy or physician in a timely manner, leading to a significant medication error.
The facility failed to provide necessary treatment and services for residents with pressure injuries, leading to immediate jeopardy. A resident with a stage IV pressure injury developed six additional injuries due to inadequate wound care and lack of proper interventions. Staff interviews revealed inconsistencies in care, and the facility did not conduct a root cause analysis for the new wounds. The facility's failure to adhere to its wound management policy resulted in a pattern of potential harm.
Two residents experienced significant changes in their conditions that were not properly monitored or reported by the facility. One resident, admitted for short-term rehab, developed respiratory issues and was not continuously monitored or reported to their provider, resulting in hospitalization for sepsis due to pneumonia. Another resident, who fell and complained of leg pain, was not assessed or monitored adequately, leading to a delayed diagnosis of a hip fracture. The facility failed to adhere to its policies for notifying changes in resident conditions.
The facility failed to maintain adequate staffing levels, resulting in unmet resident needs and compromised care. Staff and residents reported long wait times for assistance, and care plans were not followed due to understaffing. Specific incidents included a CNA working alone during a night shift, a resident left unsupervised during meals despite a choking risk, and residents not being repositioned as required, leading to concerns about skin integrity.
The facility failed to provide a meaningful activity program for residents, particularly those with cognitive impairments, as observed by surveyors. Residents were often left without stimulation, and there was a lack of documentation on activity participation. Staff confirmed the absence of structured activities, especially in the memory care unit, and the Activity Director acknowledged being overwhelmed and unsupported.
A facility failed to document and address grievances raised by a resident's family, violating its grievance policy. The family communicated concerns about care coordination, meeting scheduling, and medical conditions, but these were not recorded or followed up on. The Nursing Home Administrator was unaware of any grievances, highlighting a lapse in the grievance process.
A resident with multiple health conditions did not receive scheduled showers or assistance with oral care due to inadequate communication and documentation among staff. The resident expressed concerns about not having a toothbrush since admission and not receiving a shower until 15 days later. Staff were unaware of the resident's needs, leading to missed care opportunities.
A resident with complex medical conditions did not receive adequate fluid and meal intake due to insufficient documentation and monitoring by the facility. The care plan lacked specific daily fluid and nutritional needs, and there were significant gaps in the records of meal and fluid intake. Interviews with staff revealed inconsistencies in the documentation process, contributing to the resident's deteriorating condition, including the development of multiple pressure injuries.
A resident with severe cognitive impairment and specific dietary needs did not receive the prescribed mechanical soft diet. The resident's breakfast tray included a whole sausage patty instead of the required ground sausage. Staff interviews confirmed the error, and both the Dietary Manager and Director of Nursing acknowledged the oversight.
The facility did not ensure accurate staff postings, affecting all residents. Discrepancies between staffing schedules and postings led to inaccuracies in staff numbers and hours worked. The NHA acknowledged the mismatch and noted missing census information on several days.
Failure to Reassess Smoking Safety After Resident-Initiated Fire
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident who smoked and possessed smoking materials. The resident had multiple mental health and behavioral diagnoses, including alcohol use, generalized anxiety disorder, cocaine abuse, major depressive disorder, PTSD, and a history of restlessness, agitation, hoarding, verbal aggression, and threats toward staff. Her care plan documented that she chose to safeguard her own smoking materials in her room, was expected to adhere to the facility’s tobacco/smoking policy, and had been assessed as cognitively intact with a BIMS score of 15. The facility’s written smoking policy required that cigarettes, lighters, matches, and all tobacco products be turned in to the nurse for secure storage, prohibited smoking materials in resident rooms or on their person, and required smoking safety assessments quarterly and as needed with any change in condition or functional abilities. On the morning of 2/27/26, staff detected the smell of smoke on the resident’s hallway. An LPN reported smelling smoke while assisting another resident and directed CNAs to search rooms. CNAs discovered a wet, burned pile of ace wrap and sheet pieces on the floor of the resident’s room, several steps in front of the sink, with no active flames. The resident was not in the room at that moment but admitted to staff that she had started the fire, with one CNA reporting that the resident stated she did it on purpose and said, “We are all going to die anyways.” Staff also reported finding a knife, medications, and another item in the resident’s belongings and turning these over to the administrator. Nursing documentation noted that the resident had cut up an ace wrap and sheet and started the material on fire, that she stated she was not in her right mind and did not know why she started the fire, and that the administrator was updated. The administrator documented that staff notified him that the resident had ignited a small item in her room using a personal lighter, that he met with the resident, and that she reported burning something small near her shoe. He removed the lighter, initiated 15‑minute safety checks, and requested a review of her mental status and cognition. The resident’s care plan was updated the same day to add that she sometimes had behaviors including attempting to start a fire with her lighter, with interventions such as monitoring for danger to self or others and contacting law enforcement/administrator if the behavior recurred. However, the facility did not complete an updated Smoking and Safety Assessment immediately after the fire incident, despite the policy requirement for reassessment with changes in condition or functional abilities. Staff interviews indicated that after the incident the resident continued to have smoking materials, managed them on her own, and went in and out to smoke, while the receptionist and nursing staff reported they had not been instructed to secure her smoking materials and that she continued to safeguard them in her room lockbox. A later Smoking and Safety Assessment completed on 3/4/26, after surveyor inquiry, did not document the prior fire, did not mark burned items as a concern, and stated there were no concerns with her ability to smoke safely outside, demonstrating that the facility failed to reassess and revise her smoking safety status in response to the fire she started in her room. The surveyors determined that the facility’s failure to reassess the resident’s safety with smoking materials after she started a fire in her bedroom, and the continued care planning and allowance for her to have smoking materials on hand, constituted a failure to identify and address the risk. The facility’s own policy prohibited smoking materials in resident rooms and required secure storage and reassessment with changes in condition, yet the resident’s care plan and staff accounts showed she retained access to smoking materials and a lockbox in her room. The facility leadership stated they viewed the incident as related to mental health and not unsafe smoking, and initially did not redo the smoking assessment because they did not consider smoking itself to be the concern. These actions and inactions led to a finding of immediate jeopardy beginning on 2/27/26, later reduced to a deficiency at scope/severity level E as the facility continued to implement its action plan.
Removal Plan
- All staff re-educated on the facility's non-smoking policy prior to their next shift, including that smoking is not permitted inside the building and that smoking materials such as lighters, matches, and cigarettes must be stored at the nurse station or in an approved resident lockbox per facility policy.
- A facility wide audit was conducted to ensure residents do not possess ignition sources or weapons, and any items identified were immediately secured according to facility policy.
- All residents who smoke or possess smoking materials are being provided with a new smoking safety assessment.
- Staff were educated that any resident demonstrating unsafe behavior with smoking materials will have materials secured and will receive an immediate reassessment, with care plan interventions implemented as appropriate.
- Residents who smoke were educated regarding not using smoking materials in the facility and fire safety.
- The resident involved in the incident had smoking materials secured by staff, was reassessed for safety, and care plan interventions were updated.
- The facility generated a comprehensive list of all residents who expressed desire to smoke and completed a smoking evaluation for each identified resident along with care plan revisions.
- The facility reviewed the smoking policy and expectations regarding possession of weapons.
- Administrator or designee will conduct random audits 4 times weekly for 8 weeks on residents who smoke to ensure smoking is done safely, lighters/ignition materials are being kept appropriately or not in possession of those who are unsafe to have them, policy is followed, assessments are completed, and care plans are in place.
- Administrator or designee will conduct random audits 4 times weekly for 8 weeks of staff to ensure they know the proper procedures on what to do if a resident has a weapon.
- Administrator or designee will conduct random audits 4 times weekly for 8 weeks to ensure residents are free of weapons.
- Results of audits will be reviewed at QAPI for further recommendations.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was clinically assessed and determined appropriate to self-administer medications before doing so, as required by facility policy. The facility’s Self-Administration of Medications policy states that residents may self-administer medications only if the interdisciplinary team determines the practice is safe for the resident and others, and if there is a prescriber’s order, following an assessment of the resident’s cognitive, physical, and visual abilities during the care planning process. The resident in question was admitted with multiple diagnoses, including alcohol use, chronic pain, generalized anxiety disorder, insomnia, cerebral aneurysm (non-ruptured), cocaine abuse, homelessness, major depressive disorder, persistent mood disorder, post-traumatic stress disorder, and restlessness and agitation. The most recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact and their own decision-maker. Surveyors learned from nursing staff that the resident had medications stored in her bedroom and in a backpack, and LPNs reported that the resident would not allow staff to look through the backpack, so they did not know what medications were present. Review of the resident’s care plan and orders showed that the resident had not been assessed or care planned for safe self-administration of medications. The DON later documented that, upon going through the resident’s bag with the resident, multiple medications and supplements were found, including Topiramate 100 mg, Tylenol 500 mg, Ibuprofen 200 mg, Vitamin C 500 mg, Jet Alert, Vitamin D3 2000 IU, an iron supplement 28 mg, Docusate Sodium 100 mg, Ashwagandha pills, and Fluoxetine 20 mg. At the time of the survey, the DON acknowledged that there was no completed self-administration assessment for this resident, and that he had only recently become aware that the resident had medications in her room. The facility therefore did not ensure the resident was clinically appropriate to self-administer medications in accordance with its policy.
Failure to Control Smoking Materials and Supervise Unsafe Smoking, Including Oxygen-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and control of smoking materials, particularly for a resident using oxygen, in violation of its own smoking safety policy. One resident with COPD and chronic hypoxic respiratory failure, who required long‑term oxygen for survival benefit per physician notes, began smoking after years of not smoking. Nursing notes documented that this resident had recently started smoking, was smoking frequently, and was observed smoking in unsafe locations, including inside the building between doors and outside the main entrance rather than in the designated smoking area. Despite multiple staff observations and documentation of this new smoking behavior, the resident did not have a Resident Safe Smoking Assessment or a smoking-related care plan, and the physician’s oxygen orders referenced in progress notes were not present on the MAR/TAR. Staff documented repeated episodes of unsafe smoking by this oxygen‑dependent resident. Notes described the resident smoking outside with another resident, smoking so frequently that he missed meals and did not sleep, being caught smoking inside the doors with cigarette butts on the floor, and refusing to move to the designated smoking area even after being informed the facility was non‑smoking and that other residents with oxygen used the same entrance. On one occasion, police were called when the resident refused to comply with smoking restrictions at the main entrance. Later, the facility self‑reported that at approximately 3:00 AM the resident was found in his room smoking while oxygen was in use. Staff intervened, the resident refused to relinquish smoking materials, became physically aggressive, and bit a nurse’s hand while staff attempted to remove the lighter. Another nurse note documented a separate incident in which the same resident was again smoking in his room, refused to extinguish the cigarette, and began putting it out on window drapes after staff removed oxygen from the room for safety. The facility’s own smoking policy required that smoking be limited to designated areas, prohibited oxygen use in smoking areas, mandated a Resident Safe Smoking Assessment for smokers, and required that smoking materials be maintained by nursing staff. However, the resident who had recently started smoking and was known to use oxygen had no smoking assessment, no smoking care plan, and continued to have access to smoking materials in his room. Leadership acknowledged that a safe smoking assessment was not completed, the care plan was not updated with smoking goals and interventions, and oxygen orders were not on the MAR/TAR even though staff continued to use oxygen. Additionally, surveyors observed another deficiency when one resident handed a lighter to another resident in the hallway while an LPN remained seated at the nurse station and stated that residents had the right to keep their own smoking materials, contrary to the DON’s statement that residents were to return smoking materials to staff and not hand them off to other residents. These actions and inactions show that the facility failed to secure smoking materials per policy, failed to assess and care plan for residents who smoke, and failed to ensure staff followed established smoking safety procedures.
Removal Plan
- Educated all staff on the facility smoking policy, including resident eligibility and safe smoking practices.
- Revised the smoking policy to include provisions for residents who elect to self-store smoking materials, requiring residents to demonstrate safe management and use a locked storage box in accordance with the plan of care.
- Educated staff on proper storage of resident smoking materials at the nurses station or in approved locked boxes per the resident's plan of care.
- Trained staff on immediate actions for unsafe smoking, including redirection to securing materials, addressing oxygen risks, and notifying leadership.
- Reeducated all residents who smoke on the smoking policy and requirements for keeping materials.
- Generated a comprehensive list of all residents who expressed a desire to smoke.
- Completed a smoking evaluation for each identified resident, including care plan revisions and offering smoking cessation.
- Reviewed and updated the smoking policy.
- Administrator or designee to conduct random audits of residents who smoke to ensure safe smoking and policy compliance, assessments completed, care plans in place or updated as appropriate, and correct storage of smoking materials.
- Review audit results at QAPI for further recommendations.
Failure to Monitor and Manage Hydration Leading to Recurrent Dehydration and Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received sufficient fluids to maintain proper hydration and health. The resident was admitted with multiple significant diagnoses, including muscle wasting and atrophy, morbid obesity, polyneuropathy, chronic pain syndrome, atrial fibrillation, HTN, seizures, CKD stage 3, mood disorder, and wounds. The resident’s H&P by the NP directed that fluid status be closely monitored, but facility leadership gave differing and unclear interpretations of what this meant, and there was no documented clarification. The facility was unable to provide a hydration policy when requested by the surveyor. The RD established an estimated fluid need of 2376–2640 ml/day and documented that the resident was at risk for malnutrition, with a goal that the resident maintain good skin integrity with no signs of dehydration or malnutrition. Fluid intake records show that the resident frequently did not meet the recommended fluid goals over multiple extended periods. From late November through mid-December, the resident failed to meet fluid goals on most days, yet there is no documentation that the RD or provider were notified when intake was consistently low. The RD later stated that several stretches of poor intake should have triggered notification and additional interventions, but the RD was not informed. Nursing leadership acknowledged that when fluid goals are not met, nurses should assess the resident, evaluate skin and mucous membranes, check vital signs, and notify the provider and RD, but there was no documentation that this occurred. The resident experienced multiple changes in condition associated with dehydration and was sent to the ED/hospital three times, each time receiving IV fluids for dehydration. On the first ED visit, the resident presented with kidney pain, dry mucous membranes, and difficulty speaking; the ED provider documented very dry, shriveled tongue and lack of saliva, administered 2 L of IV fluids, and instructed that the resident be orally rehydrated with water and electrolyte drinks. There is no evidence in the medical record that electrolyte drinks were provided, that a hydration assessment was completed, or that monitoring or new interventions were implemented after this visit. Subsequent fluid intake records continued to show frequent failure to meet fluid goals, including consecutive days of poor intake, and the RD again reported not being notified of these patterns or of the ED visits and IV fluid administration. Later, the resident was sent to the hospital with altered mental status, difficulty arousing, and nonsensical speech; the hospital discharge summary documented a diagnosis of dehydration and IV hydration. After return, fluid intake again did not meet estimated needs on all recorded days, and documentation shows inconsistent or low intakes, with CNAs indicating that “not applicable” entries meant zero intake. The resident was again sent to the ED with altered mental status, difficulty staying awake to swallow food/medications, and labored respirations, and was diagnosed with dehydration and given 3 L of IV fluids. ED discharge instructions again emphasized ensuring adequate fluids. The DON stated that full nursing assessments and 72-hour monitoring should occur after hospital returns, including ensuring adequate fluid intake and daily vital signs, but acknowledged that these assessments were not found in the chart. Overall, the facility did not complete hydration assessments, did not consistently monitor and document fluid intake against established goals, did not notify the RD or provider when indicated, and did not implement additional interventions to prevent recurrent dehydration, resulting in three hospital transfers for dehydration and IV fluid treatment.
Failure to Provide and Document Required Annual CNA In‑Service Training
Penalty
Summary
The facility failed to ensure CNAs received the required 12 hours of annual in-service training, as identified through interview and record review. The facility’s policy on Required Training, Certification and Continuing Education of Nurse Aides, dated 10/1/22, states that the facility will provide at least 12 hours of in-service training annually based on the employment date, and that documentation of in-services will be forwarded to the HR Director and maintained in the employee’s personnel file. Surveyors randomly selected five CNAs and requested documentation of their annual in-service training. For CNA P, hired 2/8/23, the 2025 education record showed 10 hours of completed in-service, and a Nurse Aide Competency Form dated 3/15/25 did not indicate the number of credited in-service hours. For CNA/MA DD, hired 3/20/06, the 2025 education record showed 1 hour of completed in-service, and a Nurse Aide Competency Form dated 3/9/25 also did not indicate the number of credited in-service hours. For CNA EE, hired 5/12/13, the 2025 education record showed 1 hour of completed in-service. For CNA FF, hired 4/24/24, the 2025 education record showed 1 hour of completed in-service. For CNA GG, hired 5/23/18, the 2025 education record showed 1 hour of completed in-service, and a Nurse Aide Competency Form dated 4/22/25 did not indicate the number of credited in-service hours. During an interview, the NHA stated that the facility no longer had access to its computerized education system as of about three months prior and had moved to in-person in-services. The NHA acknowledged that CNAs should receive at least 12 hours of continuing education and that there was no documentation of 12 hours of in-service for the CNAs reviewed, which had the potential to affect all residents in the facility.
Failure to Maintain Effective Bed Bug Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests, specifically bed bugs, for four residents. One cognitively intact resident reported seeing bed bugs in her room within the past week and stated that when she informed the Nursing Home Administrator (NHA), he questioned whether she was sure because it would require removing everything from her room, and she felt he was trying to get her to say she had not seen them. Staff interviews revealed that bed bugs had been observed in multiple resident rooms within the last one to two weeks, including the rooms of residents with both intact and impaired cognition. Staff reported seeing bed bugs in the rooms of two other residents within the last week. A CNA/Medication Technician and another CNA described catching a suspected bed bug in a sealed container in the shared room of two residents, confirming its identity using the internet, stripping the beds, bagging clothing, and assisting the residents with showers while housekeeping performed a deep clean. Another housekeeper reported that staff saw bed bugs in a different resident’s room the previous night or that morning and sent photos to the Director of Maintenance. That resident’s medical record documented red, itchy bumps and bug bite-like lesions on her arms, back, and neck over several days in January. The Director of Maintenance acknowledged that bed bugs periodically appeared in the facility and described using a chemical product, Gentrol, to treat affected rooms. He stated that he mixed one ounce of Gentrol with one gallon of water in a pressure sprayer and used the same mixed solution for at least three separate treatments over a period longer than 48 hours, contrary to the manufacturer’s instructions that the diluted solution must be used within 48 hours of mixing. He also did not know when the product was purchased or when it expired. The NHA stated he was unaware that the chemicals had been donated from an outside job over five years ago and that he was unsure of the product’s expiration or open date, while also indicating that he had directed the Director of Maintenance to use facility-owned chemicals instead of calling an exterminator.
Failure to Thoroughly Investigate and Timely Report Resident-to-Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and timely report multiple resident-to-resident altercations, as required by its abuse/neglect/exploitation policies and state reporting requirements. The facility’s written policy required identification of staff responsible for investigations, interviews of all involved persons and others who might have knowledge, and complete and thorough documentation of the investigation, including submission of a final report to the state agency within five working days. The separate investigation procedure policy did not contain information on how to conduct and document a thorough investigation. For the altercation in which one resident in a wheelchair slapped another resident in the head/face three times in the dining room, the facility’s investigation file contained only the initial abuse report to the state, the misconduct incident report, and a two‑page investigation report. The investigation report stated that all staff working at the time were interviewed and that skin checks were completed on both involved residents and all other residents on the unit, but the facility could not produce documentation of these staff interviews or the additional residents’ skin checks. In this first altercation, the resident who slapped another had dementia with agitation and a BIMS score indicating moderate cognitive impairment, and the resident who was slapped had severe cognitive impairment and behavioral symptoms directed toward others. The incident report documented that the aggressor rolled up to the other resident and slapped him three times without saying anything, and that both residents were separated and assessed for injury. Staff witnesses, including a medication technician and a CNA, reported seeing the incident and removing the aggressor, but later interviews revealed they did not recall being asked for follow‑up witness statements beyond the initial incident documentation. The DON stated that investigations for resident‑to‑resident altercations should include interviews with all residents involved and all staff working that day, with all interviews documented, and that skin assessments should have been completed on other residents on the hall. However, the DON reported he had not done any skin assessments following this incident, and the administrator later verified that the skin assessments on other residents described in the investigation summary had not been completed and that only staff who directly witnessed the incident were interviewed. Angel Rounds documentation produced by the administrator showed only general observations such as appearance, clothing changes, concerns voiced, and room cleanliness, with no documentation that residents were asked if they felt safe or had witnessed abuse. The facility also failed to thoroughly investigate and timely report a separate resident‑to‑resident threat and a later physical altercation between two other residents. One resident with a history of traumatic brain injury, vascular dementia, severe cognitive impairment, and documented behavioral issues including yelling, cursing, and aggression toward others was care planned for triggers such as perceived rudeness to staff and instructed interventions including separation from altercations and one‑to‑one supervision when aggressive. Another resident, with intact cognition and behavioral issues including yelling, cursing, blocking hallways, and following staff, reported that the first resident walked up to him and said, “I’ll slap you in your face right now,” then walked away; this incident was not witnessed by staff. The initial abuse report and misconduct incident report stated that staff and resident interviews were conducted, and the investigation report asserted that all staff working during the time of the incident and any available residents were interviewed, but subsequent review showed there were no staff or additional resident interviews documented for this allegation. An additional untitled document described a later incident in which the same aggressive resident approached the same other resident in the dining room and struck him; staff were present but did not directly witness the strike, and the document stated that a comprehensive investigation with staff and resident interviews was conducted, yet the facility’s investigation file contained only one staff interview. The administrator and corporate nurse confirmed that the required five‑day follow‑up reports for both the October 3 and October 4 incidents were submitted to the state agency seven days late, and the administrator acknowledged he did not interview all staff and residents as required and had no documentation of many of the interviews he stated were done.
Failure to Obtain and Document Orders for Oxygen and Non-Invasive Ventilation
Penalty
Summary
The deficiency involves the facility’s failure to provide and manage respiratory care, including oxygen and non-invasive ventilation, in accordance with physician orders and professional standards for two residents. The facility’s oxygen administration policy requires that oxygen be administered under a physician’s order, that care plans identify specific oxygen interventions, and that equipment settings and monitoring be based on resident assessment and orders. The policy references CPAP as a delivery system but does not mention BiPAP. Despite this, residents were observed using oxygen and BiPAP/CPAP equipment without corresponding physician orders or documentation on the MAR/TAR. For one resident with COPD and chronic hypoxic respiratory failure, physician notes documented that long-term oxygen was needed for survival benefit, with a goal to maintain oxygen saturation above 90% when levels fell below 88%. These notes also described symptoms such as breathlessness, confusion, cough, disorientation, fatigue, headaches, tachycardia, and shortness of breath, and stated that the resident required oxygen equipment. However, there were no physician orders for oxygen therapy in the resident’s December or January physician orders or MAR/TAR. Facility self-reports and nursing notes documented that this resident was found smoking in his room while using oxygen, and that oxygen equipment was present and in use in the room without an order. Staff, including the DON and corporate RN, confirmed that there were no transcribed oxygen orders, and staff were unsure of the correct liter flow. For another resident with diagnoses including muscle wasting and atrophy, morbid obesity, obstructive sleep apnea, and restlessness and agitation, there were no physician orders for oxygen therapy, BiPAP, or CPAP in the physician orders or MAR/TAR over multiple months. Despite this, the ADON stated that the resident used oxygen with BiPAP at night, and an LPN stated that the resident used CPAP with oxygen. The LPN indicated that such use should be reflected in physician orders and in report, and that staff should be checking the level of oxygen delivery, but was uncertain whether it would appear on the MAR/TAR. When surveyors requested the resident’s orders for oxygen and BiPAP/CPAP, no orders were provided.
Failure to Provide Required Annual Medication-Based In-Service Training for MA
Penalty
Summary
The facility failed to ensure that a Medication Assistant (MA), who is also a Certified Nursing Assistant (CNA), received the required 4 hours of medication-based in-service training annually, resulting in a deficiency for 1 of 1 MAs reviewed. CNA/MA DD, hired on 3/20/06, had an education record for the year 2025 that documented only 1 hour of in-service training, consisting of 0.5 hours in Quality Assurance and Performance Improvement and 0.5 hours in Compliance and Ethics, with no medication-based in-service hours recorded. A Medication Administration Education for Nursing Staff form dated 11/6/25 and signed by CNA/MA DD did not include any documentation of credited in-service hours. During an interview on 2/18/26 at 2:32 PM, the Nursing Home Administrator (NHA A) stated that MAs are required to have an additional 4 hours of medication-related education annually and acknowledged there was no documentation that CNA/MA DD had completed these required 4 hours of medication-based education.
Failure to Provide and Document Required Wound Care and Assessments
Penalty
Summary
The facility failed to ensure that three residents received necessary care and services in accordance with professional standards and physician orders. Two residents with wounds did not receive all scheduled wound care treatments as ordered. Documentation showed that one resident missed wound care on multiple days due to being out of the facility or refusing treatment, with these instances recorded as refusals or absences on the Treatment Administration Record (TAR). However, there was no evidence that the physician was notified of the missed treatments, nor was there documentation that the residents were educated about the risks and benefits of missing wound care. Interviews with nursing staff and the Director of Nursing (DON) confirmed that education was not provided and that missed treatments were not consistently communicated to the physician or documented as required. Another resident receiving IV antibiotic therapy did not have daily assessments or vital signs documented, despite facility policy requiring daily monitoring for residents receiving skilled services. The resident's medical record showed vital signs were only taken on select days, and skilled charting was not completed daily during the course of antibiotic therapy. The DON confirmed that daily assessments and vital signs should have been documented for residents on IV antibiotics, but this was not done in this case. Facility policies reviewed by surveyors required that wound care be provided according to physician orders, that missed treatments be documented, and that residents be educated on the risks and benefits of refusing care. Policies also required daily vital signs and assessments for residents receiving skilled services. The survey found that these policies were not followed for the sampled residents, as evidenced by gaps in documentation, lack of physician notification, and absence of resident education regarding missed or refused treatments.
Medication Order Transcription Error for Gabapentin
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident diagnosed with polyneuropathy. Upon admission, the resident had a hospital discharge order for Gabapentin 100 mg to be administered every 8 hours, which equates to three times daily. However, the active physician orders at the facility listed Gabapentin 100 mg to be given only twice daily, scheduled at 8:00 AM and 4:00 PM. This discrepancy was not identified or corrected by facility staff responsible for entering and verifying medication orders. Interviews with the nurse practitioner, unit manager, and director of nursing confirmed that the medication should have been administered three times daily as per the hospital discharge paperwork. All interviewed staff acknowledged that the order was incorrectly transcribed and that this constituted a medication error, as the facility's policy requires medication orders to be evaluated for correct dose, route, duration, and frequency in accordance with clinical guidelines.
Failure to Protect Residents from Verbal Abuse and Neglect by CNA
Penalty
Summary
The facility failed to protect two residents from abuse, neglect, and exploitation by a Certified Nursing Assistant (CNA). One resident, with moderate cognitive impairment and significant physical limitations, reported that the CNA was rude, yelled at her, and refused to assist with compression stockings during morning care, which resulted in a fall. The resident expressed ongoing fear of the CNA, stating that the CNA's presence caused anxiety, sleep disturbances, and reluctance to use the call light for toileting assistance, which the resident attributed to developing a urinary tract infection. Multiple staff members witnessed or were aware of the CNA's behavior, including loud berating and refusal to provide care, but did not consistently report these incidents as required by facility policy and mandatory reporting laws. Another resident, who is cognitively intact and has mobility impairments, reported that the same CNA mocked her accent, belittled her, and left her in a wet incontinence brief for extended periods, resulting in discomfort and a rash. This resident stated she had reported these concerns to the Nursing Home Administrator (NHA) multiple times, but no action was taken. The NHA denied receiving any reportable incidents and dismissed the resident's concerns, despite documentation of the resident's cognitive status and lack of dementia diagnosis. Staff interviews confirmed knowledge of the residents' fears and the CNA's inappropriate behavior, yet failed to initiate proper reporting or intervention. The facility's own abuse prevention policy outlines the requirement to prohibit and prevent all forms of abuse, neglect, and exploitation, and mandates immediate reporting and protection of residents. Despite this, staff failed to report or act on clear indicators of psychological and verbal abuse, including humiliation, intimidation, and deprivation of necessary care. The affected residents experienced ongoing fear, anxiety, and emotional distress as a result of the CNA's actions and the facility's failure to intervene or ensure their safety.
Failure to Timely Report Alleged Abuse and Mistreatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but no later than two hours after the allegation was made, as required by facility policy and regulation. In one instance, a certified nursing assistant (CNA) reported an incident where another CNA was verbally berating a resident, who was left visibly upset and crying. Multiple staff members witnessed the incident and considered it psychological abuse, but not all reported it to administration as required. The resident involved had moderate cognitive impairment and expressed fear of the CNA in question. In another case, a cognitively intact resident reported to the nursing home administrator (NHA) that a CNA repeatedly mocked her accent and failed to provide timely care, resulting in emotional distress and physical discomfort. Despite the resident's repeated complaints to the NHA, the allegations were not treated as abuse and were not reported to the state agency. The NHA dismissed the resident's concerns, attributing them to memory issues, despite documentation indicating the resident was cognitively intact. The facility's own abuse policy required immediate reporting of all alleged violations to the administrator and appropriate agencies, and protection for reporters from retaliation. However, the facility did not follow these procedures, failed to foster an environment where staff and residents felt free to report abuse, and did not take all allegations seriously. As a result, allegations of abuse were not reported within the required timeframe, and appropriate authorities were not notified.
Failure to Provide Ordered G-Tube Care and Maintain Patency
Penalty
Summary
A deficiency occurred when a resident with a gastrostomy tube (G-Tube), placed due to dysphagia following a stroke, did not receive the appropriate care and treatment as ordered to maintain tube patency. The resident's hospital discharge summary specified that the G-Tube should be flushed every eight hours to maintain patency, but this order was not transcribed or clarified upon admission to the facility. For several months, the resident's Treatment Administration Record (TAR) did not include any orders for G-Tube monitoring or flushing, and there was no care plan in place for G-Tube care prior to a specific date. Observations and interviews revealed that the G-Tube site had thick, mucousy drainage and dried dark red drainage, indicating a lack of proper site care and monitoring. Staff, including CNAs and an LPN, reported that no care or interventions were being provided for the G-Tube, and that the resident and their spouse had requested tube removal. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) both acknowledged that the resident should have had a care plan and physician orders for G-Tube care, including regular flushing and site monitoring, but these were not in place or being followed. The facility's own policy required that staff caring for residents with feeding tubes be trained to recognize and report complications, and that the rationale for tube placement, current clinical status, and treatment goals be reviewed by the interdisciplinary team. Despite these requirements, the resident did not receive the ordered or expected care for the G-Tube, resulting in a deficiency related to the failure to provide appropriate treatment and services for a resident with a feeding tube.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple chronic conditions, including rhabdomyolysis, morbid obesity, diabetes, COPD, insomnia, hypertension, and major depressive disorder. The resident was admitted with significant pain and had a care plan in place that included both pharmacological and non-pharmacological interventions for pain management. Despite physician orders for several pain medications, including diclofenac, acetaminophen, morphine, and others, the facility did not ensure that all prescribed medications were available and administered as ordered. Diclofenac, a scheduled pain medication, was not available to the resident for nearly a week due to pharmacy and insurance authorization issues, and the facility did not effectively follow up with the physician or ensure timely delivery from the pharmacy. During this period, the resident consistently reported high pain levels, often rating her pain as 8 or 9 out of 10, and was observed by staff to be in significant distress, including crying and expressing that the pain was excruciating. Certified Nursing Assistants reported delays in nursing response to pain complaints, and the resident herself stated that her pain was not adequately managed, despite receiving some PRN medications such as morphine and acetaminophen. The resident was not aware that she was not receiving the diclofenac, which was part of her prescribed regimen, and reported that her pain rarely dropped below an 8 out of 10. Additionally, the facility did not implement or offer any non-pharmacological interventions for pain management, despite these being included in the facility's pain management policy and the resident's care plan. Interviews with staff and the resident confirmed that interventions such as music therapy, hot or cold packs, or massage were not provided. The facility's failure to ensure the availability of prescribed medications, lack of timely follow-up with the physician, and omission of non-pharmacological pain management approaches resulted in the resident experiencing ongoing, severe pain that was not adequately addressed according to professional standards of practice and the resident's care plan.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for several residents, leading to the development and worsening of pressure injuries. Resident R29, who was at high risk for pressure injury development due to limited mobility, incontinence, and other health conditions, developed multiple pressure injuries, including two stage 3 and one stage 2 pressure injuries. The facility did not update R29's care plan to include physician recommendations for turning and repositioning every one to two hours, and staff reported being unable to reposition R29 as frequently as care planned due to staffing issues. Additionally, the facility's use of a bariatric air mattress for R29 was compromised when the power source was partially interrupted, leaving R29 on a deflating mattress for 30 to 60 minutes without being transferred to a functioning offloading surface. This contributed to the deterioration of R29's pressure injuries. The facility also failed to consistently check the mattress settings every shift as required by the care plan. Other residents, including R49, R63, and R5, were also affected by the power interruption, as they were left on deflating air mattresses for extended periods. The facility's failure to provide consistent and adequate pressure ulcer care, as well as its inability to update care plans and respond effectively to equipment failures, resulted in harm to the residents, particularly R29, whose pressure injuries worsened significantly.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety, potentially affecting all 68 residents. During an inspection, surveyors observed several deficiencies in food storage and labeling practices. In the dry food storage area, a container of corn flakes was found removed from its original packaging without a use-by date. In the main kitchen refrigerator, six bowls of pureed bread were uncovered and undated. Additionally, in a kitchenette, opened jars of peanut butter and loaves of bread were not labeled with best-by dates, and an unlabeled glass of juice and an uncovered piece of cake were found in the refrigerator. These observations indicate a lack of adherence to the facility's policy on food receiving and storage, which requires all food items to be labeled with use-by dates and properly covered. Furthermore, the facility's kitchenette microwave was found with several multi-colored dried-on splatters inside, suggesting inadequate cleaning practices. Interviews with the Dietary Manager (DM) and a Certified Nursing Assistant (CNA) revealed uncertainty about responsibilities for checking and labeling food items and cleaning the microwave. The DM acknowledged the need for a plan to address these issues, but at the time of the survey, there was no established cleaning schedule or clear assignment of duties for maintaining food safety and hygiene in the kitchenette areas.
Inadequate Infection Control and Surveillance
Penalty
Summary
The facility lacks a comprehensive system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases among its residents and staff. The staff surveillance line lists are incomplete, missing critical information such as specific symptoms, symptom onset dates, return-to-work dates, and specific areas last worked. This deficiency is evident in the staff line lists for November 2024, December 2024, and January 2025, where numerous call-ins lack detailed symptom information and return-to-work dates, and all list 'nursing' as the last area worked without specifying a location. Similarly, the resident surveillance line lists are deficient, lacking details on symptoms, types of infections, and the specifics of precautions taken, including their start and end dates. The resident line lists for November 2024, December 2024, and January 2025 show multiple instances of residents with unknown infections, missing symptoms, and unspecified precautions. For example, in December 2024, 15 residents should have been on precautions, but the line lists do not indicate which precautions were taken or their duration. During an interview, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) acknowledged these deficiencies, noting that specific symptoms should be listed on both staff and resident line lists. The ADON/IP also confirmed that infection types, onset dates, and return-to-work dates should be documented. The ADON/IP indicated that efforts to include precautions on line lists had recently begun and would continue moving forward.
Lack of Emergency Preparedness Training During Power Outage
Penalty
Summary
The facility failed to develop, implement, and maintain an effective emergency training program for all staff, including contracted personnel, which is consistent with their expected roles and based on the facility assessment. This deficiency was identified during a survey when 15 different staff members across all three units were unable to locate emergency outlets during a partial power outage. The staff had not received training on handling electric power outages or the use of emergency outlets, which could potentially affect the entire census of 68 residents. During the survey, it was observed that the facility's power was interrupted, causing issues such as deflating air mattresses for residents. Several staff members, including CNAs, LPNs, and Med Techs, were interviewed and expressed their lack of knowledge regarding the location of emergency outlets and the procedures to follow during a power outage. Some staff members mentioned that they had not received any emergency preparedness training specific to power outages, while others were unsure if the facility even had emergency outlets. The Director of Nursing (DON) and the Director of Maintenance (DM) provided insights into the situation, indicating that the building lost partial power due to a blown fuse caused by a squirrel. The generator took an hour to activate, leaving some units without power. The DON acknowledged that staff should have been trained on emergency preparedness and the location of emergency outlets, but this training had not yet been conducted. The lack of training and preparedness led to residents experiencing discomfort and potential risks during the power outage.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and resident complaints. Several residents, including those with cognitive impairments and serious medical conditions, reported issues with the cleanliness of their rooms. Observations by surveyors confirmed these reports, noting unclean floors, dust accumulation, and debris under furniture. Specific instances included a resident with Type 2 Diabetes and a peritoneal abscess who found their room unclean, with popcorn on the floor, dirty laundry, and a bathroom handrail smeared with a brownish substance. Another resident with mild cognitive impairment and blindness was observed to have a floor in need of mopping, with foot tracks and white markings. A resident with enterocolitis and major depressive disorder reported that housekeeping did not clean their room daily, and debris was pushed under the bed. Similar issues were noted in other residents' rooms, with dust build-up along baseboards and under sinks, and small particles of debris on the floors. These conditions were consistent across multiple rooms, indicating a systemic issue with housekeeping services. The facility's housekeeping policy was not provided, and the daily check-off sheet indicated that resident rooms should be cleaned thoroughly, including mopping, sweeping, and dusting. However, the facility was experiencing staffing shortages in the housekeeping department, with two open positions. The Nursing Home Administrator acknowledged these issues and stated that the facility was working to address the staffing shortfall. Despite these efforts, the lack of adequate housekeeping services resulted in an environment that did not meet the residents' expectations for cleanliness and comfort.
Safety Hazards in Wheelchair Charging and Oxygen Storage
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for residents using motorized wheelchairs and those receiving oxygen therapy. During a survey, it was observed that a motorized wheelchair was being charged in the main dining room while residents were present, contrary to the facility's policy that requires charging to occur in a non-residential area without oxygen presence. The CNA responsible for plugging in the wheelchair was unsure of the correct procedure, and the ADON present was unaware of the policy, indicating a lack of staff awareness and adherence to safety protocols. Additionally, a resident receiving oxygen therapy had their portable oxygen tank placed on the floor of a closet with clothing hanging above it, which is against the manufacturer's guidelines for safe oxygen storage. The LPN accompanying the surveyor was initially unsure about the appropriateness of the oxygen tank's placement, highlighting a gap in staff knowledge regarding oxygen safety. The resident involved had a medical history of Chronic Obstructive Pulmonary Disease and Diabetes Mellitus Type 2, necessitating continuous oxygen therapy.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled according to professional standards, as evidenced by the presence of undated open insulin vials for four residents. The facility's policy required that when a manufacturer's container or vial is initially opened, it should be dated with an open date and a new expiration date. However, during the survey, it was observed that insulin pens for four residents were open without any indication of the open date, contrary to the facility's policy. Interviews with the nursing staff, including an LPN and the Director of Nursing, confirmed that insulin pens should be dated upon opening and are generally considered good for 28 days once opened. Additionally, the facility did not ensure that medication carts were properly secured. A surveyor observed an unlocked medication cart left unattended in a hallway, containing residents' topical medications and wound care supplies. The Assistant Director of Nursing admitted to leaving the cart unlocked and unsupervised, acknowledging that it should have been secured. Furthermore, during a medication administration observation, an LPN left several stock bottles of medications and a box of lidocaine patches on top of a locked medication cart while attending to a resident, leaving them unsupervised and accessible to others. The Nursing Home Administrator confirmed that the expectation is for all medications to be locked up when the medication cart is unsupervised. The surveyor's observations and interviews with staff highlighted lapses in the facility's adherence to medication storage and labeling protocols, which are critical for ensuring the safety and proper management of medications within the facility.
Failure to Offer Pneumococcal Vaccines to Residents
Penalty
Summary
The facility failed to ensure that each resident was offered a pneumococcal immunization, as required by their policy and CDC recommendations. Specifically, four residents were not offered the pneumococcal vaccines, and there was no documentation of declination or consent for these vaccines. The facility's policy, dated November 2017, mandates that residents be offered pneumococcal vaccines upon admission unless contraindicated or previously received. However, residents R26, R10, R25, and R9 were not offered the recommended vaccines, and there was no documentation of education or consent regarding the immunizations. Resident R26 had previously received Pneumovax 23 but was not offered the next recommended pneumococcal vaccine, PCV15, PCV20, or PCV21. Similarly, resident R10 had received Pneumovax 23 but was not offered the subsequent recommended vaccines. Residents R25 and R9 had no documentation of receiving any pneumococcal vaccines and were not offered the recommended doses. The Infection Preventionist confirmed that the vaccines were not offered to these residents, acknowledging that they should have been. This oversight indicates a failure to adhere to the facility's infection prevention and control program guidelines.
Medication Administration Deficiency for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R9, was clinically appropriate to self-administer medications. R9 was observed to have her medications left at her bedside, which is against the facility's policy. The policy requires an interdisciplinary team assessment to determine if a resident can safely self-administer medications, and R9 had not been evaluated for this ability. Despite this, R9's thyroid medication was left at her bedside, and she took it on her own later in the morning, indicating a lapse in the facility's medication administration process. R9, who has diagnoses including hypothyroidism, major depressive disorder, and ADHD, was admitted to the facility with a cognitive status indicating she was intact. However, the facility's staff, including an LPN and the DON, confirmed that R9 was not permitted to self-administer medications. The LPN stated that medications should not be left at the bedside and that staff are required to administer and observe the resident taking them. The DON also confirmed that R9 should not have a self-medication evaluation as she cannot self-administer her medications, highlighting a discrepancy between the facility's policy and practice.
Deficiencies in Care Planning for Sleep and Tube Feeding
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. One resident, who was receiving Melatonin for sleep, did not have a sleep assessment or sleep tracking completed. The resident's care plan did not indicate the use of Melatonin, despite the medication being ordered and started after the initial care plan was developed. The Director of Nursing (DON) acknowledged the lack of sleep assessments and tracking for Melatonin use, stating that they were unaware of the requirement for such assessments for over-the-counter medications. Another resident, who was receiving nourishment through a feeding tube, did not have a care plan that included instructions on how to care for the tube. The care plan focused on an infection related to the PEG tube site but did not address the care of the feeding tube itself or the nutritional needs associated with it. The DON confirmed that a feeding tube care plan was expected for residents with feeding tubes, indicating a lapse in the facility's care planning process.
Failure to Provide Personalized Activities for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the interests and well-being of a resident, identified as R264, who is legally blind and has mild cognitive impairment. The resident's preference evaluation indicated a strong interest in keeping up with the news, listening to specific music genres, and a moderate interest in being around animals. However, the facility did not document any activities offered to R264, and the resident's care plan did not reflect these interests. Observations by the surveyor revealed that R264 spent long periods sitting in a recliner in front of a television, with no evidence of engagement in meaningful activities. Interviews with the resident indicated a desire to participate in activities with others, but the resident reported not being invited to any activities by the facility. The activities coordinator admitted to not having completed a full assessment for R264 and acknowledged that the resident had not been offered activities aligned with their interests, such as listening to preferred music or engaging with animals. The facility's activity calendar listed various group activities, but there was no indication that these were tailored to R264's needs or that the resident was encouraged to participate. The activities coordinator also failed to document any activities offered to R264, despite claiming to have offered inappropriate activities like bingo and painting to the blind resident. This lack of personalized activity planning and documentation highlights a deficiency in meeting the resident's psychosocial and emotional needs.
Failure to Initiate Neurological Checks After Resident's Unwitnessed Fall
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident who experienced an unwitnessed fall resulting in a head injury. The resident, who has significant cognitive impairment with a BIMS score of 3, was found with a bruise on her forehead and hand. Despite the facility's policy requiring neurological checks for any unwitnessed fall or fall with evidence of head injury, these checks were not initiated. The Director of Nursing acknowledged that the facility did not follow the fall policy and procedure, focusing instead on the potential abuse aspect of the injury. The resident's fall investigation noted that she often gets up independently after falls without notifying staff, increasing her risk of further injury. Staff statements indicated that no falls were reported during certain shifts, and the resident had previously denied falling when questioned about shoulder pain. A full set of vitals was taken once after the fall, but continued monitoring was not conducted. The Nursing Home Administrator expressed the expectation that staff should follow the facility's fall policy and procedure, especially when there is evidence of a head injury.
Improper Catheter Care Leading to Infection Risk
Penalty
Summary
The facility failed to ensure proper care and maintenance of indwelling catheters for two residents, leading to potential risks of urinary tract infections. Observations revealed that the catheter bags of two residents were in direct contact with the floor, contrary to established guidelines for infection control. The Centers for Disease Control and the Healthcare Infection Control Practices Advisory Committee guidelines emphasize maintaining unobstructed urine flow and keeping catheter bags off the floor to prevent infections. Despite these guidelines, the surveyor observed the catheter bags of both residents resting on the floor during multiple visits. Resident R63, who was admitted with diagnoses including Type 2 Diabetes Mellitus and Chronic Kidney Disease, and Resident R26, with benign prostatic hyperplasia and a history of urinary tract infections, were both affected. Staff members, including a CNA, Med Tech, LPN, and the Director of Nursing, acknowledged that catheter bags should not be in contact with the floor due to infection control concerns. However, during the surveyor's observations, the catheter bags were repeatedly found on the floor, indicating a lapse in adherence to proper catheter care protocols.
Medication Administration Deficiency for Resident
Penalty
Summary
The facility failed to ensure the proper administration of pharmaceutical services for a resident, identified as R9, who was observed self-administering levothyroxine at 11:17 AM, despite the medication being scheduled for 6 AM. The facility's policy mandates that medications be administered by authorized personnel and within 60 minutes of the scheduled time, with residents only allowed to self-administer medications if specifically authorized by a physician. However, R9's levothyroxine was left at the bedside, and R9, who is cognitively intact, took the medication later than scheduled, indicating a deviation from the facility's medication administration policy. Interviews with facility staff, including an LPN and the DON, revealed that R9 was not authorized to self-administer medications, except for an inhaler, and that medications should not be left at the bedside. The LPN confirmed that the third shift nurse is responsible for administering R9's levothyroxine between 5 AM and 6 AM and acknowledged that the medication was administered late. The DON also confirmed that medications should not be left at the bedside for R9, highlighting a failure in the facility's medication administration process.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program, which includes protocols and a system to monitor antibiotic use, for two residents. One resident, identified as R57, was treated with antibiotics for a urinary tract infection (UTI) without documentation of Culture and Sensitivity (C&S) testing. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed that without the C&S, it could not be determined if the criteria for antibiotic treatment were met. The resident had been admitted from an emergency department with a UTI diagnosis and orders for Cephalexin, but the facility did not have the necessary documentation to support the treatment decision. Another resident, R26, was also treated with antibiotics for a UTI without appropriate indication. The facility lacked documentation of urinalysis (UA) and C&S for two separate instances in December 2024 and January 2025. The Infection Preventionist was unable to provide information on the signs and symptoms that justified the antibiotic treatment, and the Director of Nursing (DON) acknowledged that the facility should have obtained a C&S to ensure the correct antibiotic was administered, especially given the resident's history of sepsis. The facility's policies on antibiotic stewardship and infection surveillance were not followed, as evidenced by the lack of documentation and failure to verify the appropriateness of antibiotic orders. The DON admitted that the process for handling residents returning from the emergency department with antibiotic orders was not adequately executed, as the necessary lab results and criteria assessments were not completed. This oversight in monitoring and documenting antibiotic use led to the deficiency identified by the surveyors.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure accurate administration of medication for a resident, identified as R2, who did not receive two doses of a scheduled intravenous antibiotic, daptomycin, upon admission. The facility's Medication Administration policy requires that medications be administered as prescribed and that the physician be notified if vital medications are withheld or unavailable. However, R2's medical record did not indicate that the physician was notified about the missed doses of daptomycin. Additionally, the Director of Nursing (DON) confirmed that the nurses should have informed R2's physician if the medication was not available. Furthermore, multiple medication orders for R2 were transcribed incorrectly, leading to the resident not receiving medications as ordered. The orders for desvenlafaxine, hydroxyzine, trazodone, and gabapentin were entered with incorrect stop dates, resulting in R2 going several days without these medications. The DON verified that the nurse who entered the orders mistakenly thought psychotropic medications were only prescribed for 14 days and failed to update or clarify the orders with the physician. As a result, R2 experienced increased pain and sleep disturbances due to the lack of medication, as confirmed by R2 during an interview.
Bedrock Corporation's Financial Mismanagement Leads to Service Disruptions
Penalty
Summary
The Bedrock Corporation governing body failed to ensure adequate funds were available for the safe and efficient management of the facility, affecting all 54 residents. The corporation did not maintain current payment status with several service providers and vendors, leading to service disruptions and discontinuation notices. The facility's pharmacy provider, Alixa Pharmacy, was terminated after a past due notice, and the account is currently in litigation. Additionally, the corporation owes significant amounts to other vendors, including Sysco, Synapse Health, Point Click Care, Twinmed, Comprehensive Therapy Specialist, CMS, and the Wisconsin Division of Medicaid Service. The surveyor reviewed an aging vendor report indicating outstanding balances owed to multiple vendors, with some debts extending beyond 151 days. For instance, Sysco, a food products company, is owed $43,128.56, and the corporation's line of credit is at risk of being cut off due to non-payment. Synapse Health, the facility's DME provider, is owed $2,995.11, and the company has threatened to stop providing services if payment is not received. Point Click Care is owed $16,683.44, and a demand letter has expired, putting the account at risk for service disruption. The facility also owes CMS $244,475.99 for Civil Money Penalties and has a significant bed tax assessment owed to the Wisconsin Division of Medicaid Service. Other vendors, such as Marshfield Laboratory and Sterling Therapy, are also owed substantial amounts, with some on payment plans. The facility owner acknowledged the issues and stated efforts are being made to pay the bills, but the lack of timely payments has resulted in potential service disruptions and negatively impacts the quality of care and life for the residents.
Resident Misses Multiple Doses of Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the resident not receiving the prescribed Nystatin suspension for several consecutive days. The resident, who was cognitively intact and had a history of metabolic encephalopathy, morbid obesity, Type 2 Diabetes Mellitus, Bipolar Disorder, and Polyneuropathy, was supposed to receive Nystatin to treat a fungal infection in the oropharynx. However, the medication was not administered as scheduled on multiple occasions, leading to discomfort and visible symptoms of the infection. The deficiency was further compounded by the facility's failure to follow its own medication reordering policy, which requires timely communication with the pharmacy and physician when medications are unavailable. The Medication Technician admitted to not contacting the pharmacy or physician when the medication was not administered, and the Director of Nursing acknowledged that the physician should have been notified earlier. This lack of communication and adherence to policy resulted in the resident not receiving necessary treatment for their condition.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure injuries, leading to a finding of immediate jeopardy. Six residents, including one with a stage IV pressure injury upon admission, did not receive appropriate wound care. This resident developed six additional pressure injuries while in the facility, and there were multiple instances where wound care orders were not completed or transcribed. The facility's policy required evidence-based treatments and physician orders for wound care, but these were not consistently followed, resulting in worsened conditions for the residents. The report highlights that the facility did not implement further or more aggressive actions as the risk for pressure injuries increased, as indicated by worsening Braden Scale scores. The resident's care plan included interventions such as pressure-reducing devices and regular repositioning, but these were not adequately executed. Observations showed that residents were not assisted with repositioning or using the restroom for extended periods, and there were significant gaps in the documentation of wound care treatments. Interviews with staff revealed inconsistencies in the care provided, with some staff acknowledging the lack of adequate repositioning and wound care. The facility did not conduct a root cause analysis to understand how the additional wounds developed, and there was a lack of communication with family members regarding the resident's condition. The facility's failure to adhere to its wound management policy and ensure proper care for residents with pressure injuries resulted in a pattern of potential harm.
Removal Plan
- Skin sweep will be completed.
- Audit will be completed of all residents to ensure their risk for developing pressure injuries have been identified with robust care plan interventions in place to reduce risk of developing pressure injuries or worsening of current pressure injuries.
- All current wounds will be reviewed to ensure treatment orders are in place.
- Education will be provided to all nursing leadership regarding monitoring of the wound management program.
- Education will be provided to all licensed staff and CNAs regarding turning and repositioning.
- Education will be provided to licensed staff regarding completing weekly skin assessments, documentation in the TAR when completing treatments, and ensuring treatment orders are in place for all wounds.
- Education will be provided on reviewing risk for pressure injuries on admission to ensure robust interventions are in place to reduce risk of developing pressure injuries or worsening of current pressure injuries.
- Pressure injury and prevention as well as wound management policy were reviewed.
- All new admissions will be reviewed for pressure injury risk to ensure robust interventions are in place to reduce risk for developing pressure injuries or worsening of current pressure injuries.
- Audits will be completed with wound rounds to ensure treatment orders are in place for all wounds.
- Treatment administration record will be audited to ensure treatments are completed as ordered and documentation is present in the medical record.
- Audits will be completed to ensure residents are provided turning and repositioning as per their plan of care.
Failure to Monitor and Report Changes in Resident Conditions
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice for two residents, R3 and R12, who experienced changes in their conditions. R3, who was admitted for short-term rehabilitation and wound care, had a change in respiratory status on 5/8/24. Despite experiencing shortness of breath and being placed on oxygen, there was no evidence of continuous monitoring or timely updates to R3's provider. This lack of action resulted in R3 being sent to the hospital on 5/10/24 with sepsis due to pneumonia. The facility's documentation did not include a lung assessment or monitoring of R3's respiratory status, and the PRN oxygen order was not documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). R12 experienced a change in condition following a fall on 6/5/24, which resulted in increased complaints of leg pain. Despite the known fall, the facility did not conduct a comprehensive assessment or continuous monitoring of R12's condition. R12 was later found to have a hip fracture. The facility's 'Falls Management Process' requires a complete head-to-toe assessment following a fall, but this was not performed. Additionally, there was a delay in administering pain medication and assessing the effectiveness of the medication, leading to inadequate pain management for R12. The facility's 'Notification of Changes Policy' mandates immediate notification of changes in a resident's condition to the resident, their representative, and the attending physician. However, this policy was not followed for both R3 and R12. The facility failed to update the care plans and communicate changes to the care team, resulting in a lack of continuity of care and delayed treatment for both residents. These deficiencies highlight the facility's failure to adhere to its own policies and procedures, leading to adverse outcomes for the residents involved.
Staffing Deficiencies Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of all residents, affecting their physical, mental, and psychosocial well-being. Observations and interviews revealed that staff were unable to complete necessary tasks due to understaffing, leading to residents experiencing long wait times for call light responses and assistance with personal care needs such as meals, repositioning, and toileting. Family members also expressed concerns about the lack of adherence to care plans and physician orders due to insufficient staffing. Specific incidents highlighted in the report include a CNA working alone during a night shift, which was deemed unsafe and resulted in a resident fall. Another resident, who required 1:1 supervision during meals due to a choking risk, was left unsupervised multiple times. Additionally, several residents at risk for skin breakdown were not repositioned or assisted with toileting as required by their care plans, leading to concerns about their skin integrity and overall care. Interviews with staff, including CNAs, LPNs, and the Director of Nursing, confirmed the ongoing issue of inadequate staffing, which hindered their ability to provide necessary care. The Nursing Home Administrator acknowledged the problem and stated that efforts were being made to address staffing shortages, but the facility continued to struggle with maintaining appropriate staff-to-resident ratios as outlined in their Facility Assessment Tool.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the interests and well-being of its residents, specifically affecting four residents. The deficiency was identified through observations, interviews, and record reviews, revealing that the facility did not create an activity program based on the current residents' interests, preferences, and familiar routines. The facility also failed to collect data or track activity attendance for the residents to determine the effectiveness of the programs in place. The report highlights that residents, including those with Alzheimer's disease and other cognitive impairments, were not engaged in meaningful activities. For instance, one resident with severe cognitive impairment had a care plan that included sensory stimulation and activities related to past interests, but the activity participation review was blank, and there was no documentation of activity attendance for two months. Another resident, who preferred quieter areas and had a short attention span, had an outdated activity participation review, and the facility could not provide recent documentation of their activity involvement. Observations by the surveyor noted that residents were often left without stimulation or interaction, with some sitting in front of a silent television or sleeping in hallways. Staff interviews confirmed the lack of structured activities, particularly in the memory care unit, and the Activity Director admitted to being overwhelmed and lacking support. The facility's failure to ensure meaningful activities and proper documentation of participation levels was evident, as was the absence of an activity calendar for the memory care unit.
Failure to Document and Address Grievances
Penalty
Summary
The facility failed to ensure that residents and their families could voice grievances without discrimination or reprisal, as required by their grievance policy. This deficiency was identified for one resident, whose family had raised multiple concerns via email to the facility's social worker. These concerns included issues related to the scheduling and communication of a meeting regarding the resident's care, lack of transparency in contacting the resident's personal medical staff, and concerns about the resident's current medical conditions, including a stage 4 wound and a UTI. Despite these concerns being communicated, there was no documentation of these grievances in the facility's grievance logs, nor was there evidence of follow-up or resolution. The facility's policy mandates that grievances be recorded and addressed promptly, with the Grievance Official responsible for overseeing the process. However, in this case, the Nursing Home Administrator was unaware of any grievances for the resident in question, and the facility failed to document or follow up on the family's concerns. This lack of documentation and follow-up indicates a failure to adhere to the facility's grievance policy, resulting in the deficiency noted by the surveyor.
Failure to Provide Scheduled Showers and Oral Care Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for a resident, identified as R1, who was unable to perform activities of daily living independently. R1, who was admitted with multiple diagnoses including diabetes, obesity, and major depressive disorder, expressed concerns about not receiving scheduled showers and assistance with oral care. The facility's policies on bathing and oral care were not adhered to, as R1 did not receive a shower until 15 days after admission and lacked a toothbrush since arrival. Observations and interviews revealed that R1 was in need of oral care and had not been assisted with brushing teeth since admission. The facility's documentation showed inconsistencies in the assistance provided, with records indicating varying levels of assistance for oral hygiene and missed showers. Staff members, including CNAs, were unaware of R1's needs due to a lack of proper communication and documentation, leading to missed care opportunities. The Nursing Home Administrator acknowledged the expectation for staff to follow care plans and document any missed showers or oral care needs. However, the surveyor found no documentation in the 24-hour notes or progress notes indicating that R1 still required a shower. This lack of documentation and communication among staff resulted in the facility's failure to ensure that R1 received the necessary personal care assistance as outlined in the care plan.
Failure to Document and Monitor Resident's Nutritional and Hydration Needs
Penalty
Summary
The facility failed to ensure that a resident, identified as R3, received sufficient fluid and meal intake to maintain proper hydration and health. R3's fluid and meal intakes were not documented daily, which is a violation of the facility's policies on hydration and nutrition management. The facility's policy requires nursing staff to assess hydration status upon admission and throughout the resident's stay, and to document fluid status in the resident's record. However, there were numerous instances where R3's fluid intake and meal consumption were not documented, making it impossible to determine if R3 met her daily fluid and nutritional needs. R3 was admitted to the facility for short-term rehabilitation and wound care, with multiple diagnoses including cancer, acute respiratory failure, paraplegia, and heart failure. Despite these complex medical conditions, R3's care plan did not specify her estimated daily fluid or nutritional needs. The care plan included interventions such as monitoring meal consumption and offering supplements, but there was a lack of documentation to confirm these interventions were effectively implemented. Interviews with facility staff revealed inconsistencies in the documentation process, with CNAs responsible for recording meal and fluid intake, but significant gaps in the records were noted. The lack of documentation and monitoring contributed to R3's deteriorating condition, as evidenced by the development of multiple pressure injuries. Interviews with staff, including the LPN, CNA, RD, and DON, highlighted a lack of communication and follow-up regarding R3's nutritional and hydration status. The RD acknowledged missing documentation and confirmed that R3 was not meeting her caloric and fluid needs. The DON admitted that the facility could not confirm if R3 met her daily requirements due to the lack of documentation. This deficiency in care and documentation led to a failure in maintaining R3's health and hydration needs, as required by the facility's policies.
Failure to Provide Prescribed Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure that a resident received the appropriate mechanical soft textured diet as prescribed by the attending physician. The resident, identified as R7, who has severe cognitive impairment and medical conditions including epileptic seizures and muscle wasting, was observed receiving a breakfast tray that did not comply with the prescribed mechanical soft diet. Specifically, the tray included a whole sausage patty instead of the required ground sausage, which is the therapeutic alternative for a mechanical soft diet. The deficiency was identified through observations and interviews conducted by the surveyor. The Certified Nursing Assistant (CNA) responsible for delivering the tray was unsure if the items were appropriate for a mechanical soft diet and confirmed with dietary staff that the tray was incorrect. The Dietary Manager acknowledged that the sausage should have been ground, and both the Director of Nursing and the Director of Therapy confirmed that the resident should have received the correct textured diet according to physician orders and therapy recommendations.
Inaccurate Staff Postings and Schedules
Penalty
Summary
The facility failed to ensure that staff postings were accurate, affecting all 56 residents residing at the facility. Discrepancies were found between the staffing schedules and the required staff postings, leading to inaccuracies in the total number of staff and the actual hours worked by licensed and non-licensed staff responsible for resident care during each shift. Specific instances of these discrepancies were noted on various dates, where the number of CNAs, LPNs, and medication technicians working differed between the staff postings and the staffing schedules. Additionally, the census information was missing on several days, further contributing to the inaccuracies. The Nursing Home Administrator (NHA) acknowledged that the schedules and postings should match and indicated that the scheduler is responsible for filling out the staff postings daily and updating them each shift. However, the review revealed that this was not being done consistently, resulting in mismatched records. The NHA also noted that the form should include the census, which was missing on multiple occasions. These inaccuracies in staff postings and schedules could potentially impact the quality of care provided to the residents.
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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