Clark County Rehabilitation & Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Owen, Wisconsin.
- Location
- W4266 County Highway X, Owen, Wisconsin 54460
- CMS Provider Number
- 525403
- Inspections on file
- 28
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Clark County Rehabilitation & Living Center during CMS and state inspections, most recent first.
Multiple cognitively impaired residents with known behavioral or wandering histories physically assaulted other residents in separate incidents. In one case, a resident with an impulse disorder struck another resident who verbally intervened when staff attempted to redirect him from taking a meal tray. In another, a resident with a conduct disorder punched a wandering resident who entered his room and could not be redirected. A third incident occurred when a resident with severe dementia and wandering behaviors entered another resident’s room, took his blanket, and hit him when he tried to retrieve it. In the fourth incident, a severely cognitively impaired, wandering resident grabbed and yelled at another resident over a TV remote. These events occurred despite documented cognitive and behavioral issues and an abuse policy stating residents will be free from abuse and protected from harm.
The facility failed to follow its abuse policy by not removing staff implicated in abuse or misconduct allegations from resident care and by not conducting thorough investigations. In one case, a resident with a serious mental health condition alleged abuse by a CNA, yet the CNA continued to work multiple shifts during the investigation. In another case, a resident with paraplegia and anxiety alleged that a floating CNA stole his clothing; the CNA continued working and no residents were interviewed as part of the investigation. In a third incident, a resident with dementia who wandered into another resident’s room was punched multiple times by that resident, who had a history of behavioral issues, and the subsequent investigation relied on only one staff interview.
The facility did not ensure all staff received required training on abuse, neglect, exploitation, and dementia care, as evidenced by missing or incomplete education records for several staff members and confirmation from the DON that some new hires and casual staff had not completed necessary training. This deficiency has the potential to affect all residents.
The facility failed to follow its abuse prevention and reporting policies after two residents were subjected to inappropriate physical restraint and medication administration, and allegations of abuse were not reported to the state agency or law enforcement. Staff involved continued to work after the incidents, required notifications and investigations were not completed, and staff training on abuse prevention was inconsistent and inadequately documented.
A resident with severe cognitive impairment and a court-appointed guardian was involved in a substantiated abuse incident. Despite facility policy and the resident's care plan requiring notification, the guardian was not informed of the incident or the investigation findings. The DON could not provide documentation of any such notification, and the guardian confirmed she was unaware of the event.
Staff used physical force to administer court-ordered psychotropic medications to a resident with severe cognitive impairment, holding the resident's arms and face despite the absence of aggression. The care plan directed disguising medications in food or drink and did not authorize physical restraints, nor was there a physician order for such use. Documentation failed to reflect alternative interventions or reasons for refusals, and the incident was later substantiated through staff interviews and facility investigation.
The facility did not follow required procedures for reporting and investigating allegations of abuse involving two residents with cognitive and psychiatric conditions. In both cases, allegations were not reported to the State Agency or law enforcement as required, and staff decisions were influenced by prior unfounded reports and concerns about late reporting.
A resident with cognitive and psychiatric diagnoses was the subject of an abuse allegation reported by a family member to law enforcement. Although police visited the facility and staff notified supervisory and protective parties, no investigation into the abuse allegation was conducted, contrary to facility policy. The DON stated that prior similar allegations were unfounded and did not believe this report required investigation.
A resident with multiple psychiatric diagnoses received prescription medications administered by a CNA, who had not completed medication administration training, using physical assistance and under direct RN supervision. This practice was contrary to facility policy, which restricts medication administration to licensed staff, and resulted in a deficiency.
Three cognitively intact residents with significant medical conditions repeatedly voiced concerns about staff shortages, long call light response times, and overheard staff conversations in resident council meetings, but did not receive timely updates or follow-up from administration or staff, contrary to facility policy. Interviews confirmed a lack of formal process for addressing and communicating actions taken on these concerns.
Two residents with cognitive impairment were involved in separate incidents of verbal and physical abuse, including one resident being threatened and another being struck in the face by a peer. Both incidents resulted in injury and were confirmed by the DON as abuse.
Two residents, both cognitively intact, were involved in a physical altercation after a verbal dispute. Although the facility's policy required a thorough investigation including resident statements, staff did not interview other residents or take further investigative steps, and the DON considered the event isolated, resulting in an incomplete investigation.
A resident with a history of chronic suicidal ideation expressed a desire to kill herself, but CNAs failed to follow the care plan by not notifying nursing staff or providing required supervision. Instead, the resident was left alone in her room, and the incident was not documented in the progress notes or communicated to the nurse or Nurse Care Coordinator. The care plan's interventions, including immediate assessment and one-to-one supervision, were not implemented.
Two residents at risk for falls were subjected to the use of multiple alarms without consistent implementation of non-alarm interventions or a documented plan to reduce alarm use. Despite facility policy requiring short-term alarm use and regular review, both residents had several alarms in place simultaneously, with incomplete assessments and missing documentation of alternative strategies. Alarms failed to prevent falls, and care plan interventions such as gait belt use were not consistently followed.
A resident's right to privacy was violated when facility staff opened their mail without permission. The resident, who is cognitively intact and a registered sex offender, had previously signed a waiver during probation allowing mail to be opened, but this probation ended years ago. Despite this, the facility continued the practice without a current waiver, contrary to their policy on mail privacy.
The facility did not conduct annual performance reviews for CNAs, affecting three CNAs and potentially impacting all 147 residents. The HR Manager confirmed the absence of a system for conducting these reviews.
A facility failed to report a resident-to-resident altercation and submit the required investigation within the stipulated timeframe. A resident with dementia and behavioral issues attempted to take candy from another resident, resulting in a willful slap. Despite the care plan's interventions, the incident occurred, and the DON acknowledged it should have been reported as willful misconduct.
The facility failed to provide written transfer notices to two residents who were hospitalized. One resident, who was cognitively intact, requested a hospital transfer due to a fever but did not receive a written notice. Another resident with multiple diagnoses was also transferred without a written notice. The DON confirmed that the facility does not issue such notifications.
A resident with Huntington's disease and pneumonitis required the head of the bed to be elevated during and after tube feeding, as per their care plan. However, a surveyor observed that the resident was positioned flat during feeding, contrary to the care plan. RN C acknowledged the oversight and adjusted the bed after being prompted. Discussions with RN D and the DON confirmed the expectation to follow the care plan, highlighting a deficiency in care implementation.
A facility failed to provide adequate supervision and safety measures for two residents. One resident, with dementia and seizure disorder, experienced falls due to improperly placed chair alarms. Another resident, with behavioral issues, was involved in an altercation due to insufficient 1:1 supervision by a new CNA. The incidents highlight lapses in following care plans and staff training.
The facility did not follow professional standards for food service safety by transporting uncovered food items to residents' rooms. CNAs were observed carrying trays with uncovered cake and drinks to three residents, contrary to the facility's policy requiring all food to be covered during transport. The Director of Hospitality acknowledged that food and drinks should be covered when leaving the dining area.
A facility failed to ensure a resident received a pneumococcal vaccine. The resident, with severe cognitive impairment and chronic conditions, was admitted without proper immunization review. The Infection Preventionist and RN could not provide proof of vaccination or a clear process for residents transferring between units, leading to the oversight.
A resident developed a stage 2 pressure injury on the coccyx, which healed over a month later. The facility failed to update the resident's care plan or repositioning schedule to prevent further pressure injuries, despite the resident's immobility and incontinence. Observations showed the resident was seated in a wheelchair for extended periods without repositioning, and staff were unaware of necessary changes to the care plan.
The facility failed to timely report an allegation of sexual abuse involving a resident with multiple diagnoses. A family member reported the allegation to a nurse, but it was not reported to the State Agency or police until several days later, violating the requirement to report within 2 hours.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents. One incident involved a resident with moderately impaired cognition and an impulse disorder who attempted to take another resident’s meal tray. When a CNA tried to redirect him, he became agitated. Another resident, who was helping place trays on tables, verbally confronted him about his behavior toward the CNA. In response, the impulsive resident struck the intervening resident on one arm, and when the resident laughed, he struck the other arm before the CNA could intervene. The resident who struck the other had a care plan noting impaired cognition, an impulse disorder, and a history of impulsive behaviors. A second incident involved a cognitively impaired resident with a history of wandering who entered another resident’s room and could not be redirected by the CNA. The room’s occupant, a resident with a conduct disorder and a history of behavior toward others, yelled at the wandering resident and then got out of bed and punched him three times in the left upper arm with a closed fist. The wandering resident then left the room and sat in a chair in the hallway. Both residents had documented cognitive impairment, and the aggressor had a known behavioral history, yet the altercation still occurred when the wandering resident entered his room and staff were unable to redirect him. A third incident involved a resident with severe cognitive impairment, Alzheimer’s disease, dementia with agitation, and documented physical, verbal, and wandering behaviors who entered another severely cognitively impaired resident’s room, mistakenly believing it was his own, and took the other resident’s blanket. The room’s occupant became upset and tried to remove the intruding resident and retrieve his blanket, leading the intruder to hit him in the chest and shoulder. The CNA heard yelling, found both residents in the room, and observed them hitting each other before separating them. Both residents had severe cognitive impairment, and one had known wandering and behavioral issues. A fourth incident involved a resident with moderate cognitive impairment and no documented behavioral symptoms during assessment who was watching television when another resident with severe cognitive impairment and wandering behaviors came out, picked up the remote, changed the channel, and set the remote down. When the first resident picked up the remote to change the channel back, the cognitively impaired, wandering resident grabbed his wrist and yelled and swore at him, telling him to leave it alone. The two residents then yelled at each other until staff separated them. The facility’s abuse policy states that each resident will be free from abuse, including physical abuse, and that residents will be protected from abuse, neglect, and harm while residing at the facility, but these resident-to-resident physical altercations occurred despite known cognitive and behavioral issues in the aggressor residents.
Failure to Remove Alleged Abusers and Conduct Thorough Abuse Investigations
Penalty
Summary
The deficiency involves the facility’s failure to remove staff members implicated in abuse allegations from resident care and to conduct complete investigations into those allegations. For one resident with schizoaffective disorder–bipolar type, an abuse allegation was documented on a misconduct incident report dated 02/20/26 involving a CNA and another resident. The DON confirmed that the CNA remained on the work schedule throughout the investigation, despite the facility’s abuse policy requiring immediate removal of alleged perpetrators from the facility pending investigation. Timecard records show that this CNA continued to work multiple shifts on and after the date of the allegation. In a separate incident, a resident with paraplegia due to thoracic spinal cord injury and an anxiety disorder alleged that a floating CNA had stolen his red long-sleeved shirt. The misconduct incident report documented that the resident was upset and expressed harm toward the CNA, and the DON stated that the CNA was reassigned to another unit during the investigation. However, the resident reported that the CNA was told only to stay away from him and that the CNA was not removed from resident care. Timecard records confirm that the CNA continued to work multiple shifts during the investigation period. The DON also confirmed that no residents were interviewed as part of this investigation, and the facility had no evidence of any resident interviews. Another deficiency occurred in the investigation of an incident in which a resident with dementia and a history of wandering entered the room of a resident with conduct disorder and a history of behavior toward others. According to the misconduct incident report dated 2/16/26, the wandering resident repeatedly entered the other resident’s room despite redirection attempts by a CNA, leading the resident in the room to get out of bed and punch the wandering resident three times on the left upper arm before the wandering resident left and sat in a hallway chair. The DON later confirmed that only one staff member, the CNA involved, was interviewed during the investigation and acknowledged that all staff should have been interviewed, indicating that the investigation was not complete or thorough. The facility’s abuse policy states that residents will be protected from alleged offenders and that alleged perpetrators will be immediately removed from the facility pending a thorough investigation, which was not followed in these cases.
Failure to Ensure Staff Training on Abuse, Neglect, Exploitation, and Dementia Care
Penalty
Summary
The facility failed to ensure that all staff received required training on abuse, neglect, exploitation, and dementia care, as outlined in its own policy. The policy states that staff and volunteers must receive education on resident mistreatment, neglect, abuse, exploitation, and misappropriation of property upon hire and annually thereafter. However, review of staff education records revealed that one CNA did not have documented abuse education training, and another CNA's annual training was missed due to their casual employment status. Additionally, the RN's training was not up to date. Interviews with staff and the Director of Nursing (DON) confirmed that there were lapses in the completion and monitoring of required training. The DON acknowledged that new hire training was not completed for at least one CNA before they began working with residents and that there may be other staff with lapses in annual training due to the transition to a new tracking system. These deficiencies have the potential to affect all 134 residents in the facility.
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its policies and procedures to prevent and respond to abuse, neglect, and misappropriation of resident property. In one incident, a certified nursing assistant (CNA) was instructed to physically restrain a resident while another CNA administered medication, which involved holding the resident's arms and face and forcibly giving medication. This incident was not immediately reported to the Director of Nursing (DON) or the Nursing Home Administrator, and the accused staff continued to work in the facility for several days after the incident before it was reported. The facility did not submit a required facility-reported incident to the state agency for two separate abuse allegations, nor did it report the abuse to law enforcement or notify the resident's representative. Additionally, a full investigation into the allegations of abuse for two residents was not completed, and there was a lack of documentation regarding notification of the resident's representative. The report also details that staff education on abuse, neglect, mistreatment, and misappropriation of resident property was not consistently completed upon hire or annually. One CNA did not have recorded abuse education training, and the system for ensuring all staff received required training was inadequate, relying only on nurse clinical coordinators to monitor completion. Signed memorandums for re-education after the incident did not include all staff signatures and did not cover the full scope of the abuse policy, such as ensuring resident safety, reporting to state agencies, and law enforcement notification. The DON acknowledged that some staff had lapses in annual training and that a new system for tracking training was still being developed. In another incident, law enforcement was contacted by a resident's family member regarding an allegation of abuse. Although law enforcement visited the facility, the facility did not submit a facility-reported incident to the state agency. The DON stated that the allegation was not reported or investigated because it was believed to be unfounded due to previous similar reports. The facility's failure to report, investigate, and document these incidents, as well as to ensure staff were properly trained, represents a breakdown in the implementation of its abuse prevention policies and procedures.
Failure to Notify Guardian of Abuse Allegation and Investigation Findings
Penalty
Summary
The facility failed to notify the legal guardian of a resident with severe cognitive impairment about an allegation of abuse and the subsequent investigation findings. The resident, who had diagnoses including anxiety disorder, depression, personality disorder, and unspecified psychosis, was under a court-appointed permanent guardianship due to incompetency and was subject to an involuntary order to treat with psychotropic medications. The resident's care plan specifically required that the physician and guardian be notified of any change in condition, including medication non-compliance. Despite this, when an allegation of staff abuse involving the resident was reported and substantiated, there was no documentation that the guardian was informed of either the incident or the investigation results. During the survey, the guardian confirmed in an interview that she had not been notified of the incident or the findings, and this was the first time she was hearing about the event. The facility's policy required that the resident or their representative be informed of any incident and the results of investigations. The DON stated she believed the guardian had been notified but could not provide documentation to support this. The lack of notification to the guardian was confirmed through record review and interviews.
Inappropriate Use of Physical Restraints During Medication Administration
Penalty
Summary
Facility staff failed to ensure that a resident was free from the use of physical restraints not required to treat medical symptoms. The facility's policy requires that physical restraints only be used after a comprehensive assessment, as a last resort, and with a physician order and consent from the resident's legal representative. However, staff used physical force to administer oral psychotropic medications to a resident with severe cognitive impairment and a history of psychiatric disorders, including anxiety, depression, and psychosis. The resident had a court order for involuntary medication, and the care plan specified disguising medications in food or drink, but did not include the use of physical restraints for medication administration. On two occasions, staff members held the resident's arms and face to forcibly administer medications by mouth, despite the resident not being physically aggressive but attempting to push the medications away. One CNA held the resident's hands above his head and then at his sides, while another held the resident's face to open his mouth, and a nurse supervised the process. Staff justified their actions by citing the court order for medication, but there was no physician order for the use of physical restraints, nor was this intervention included in the care plan. The medication administration record did not document reasons for refusals or alternative interventions attempted. The incident was reported by a CNA who expressed concern about the use of force, and an internal investigation substantiated the allegation of inappropriate use of physical restraints. The facility's documentation and staff interviews confirmed that the use of physical force occurred during medication administration, in violation of facility policy and regulatory requirements. The resident's care plan and physician orders did not authorize the use of physical restraints for this purpose.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of alleged physical abuse in accordance with federal and state requirements. In two separate cases, allegations of abuse involving two residents were not reported to the State Agency or local law enforcement as required. In the first case, local law enforcement notified the facility of an abuse allegation concerning a resident with cognitive impairment and psychiatric diagnoses, but the facility did not submit a Facility Reported Incident (FRI) to the State Agency. The Director of Nursing (DON) stated that due to previous unfounded reports from the resident and his sister, the facility did not believe the allegation warranted reporting or investigation. In the second case, a resident with psychiatric and cognitive diagnoses was subjected to physical restraint and threats by staff during medication administration, as witnessed by a CNA. The CNA reported the incidents to a nurse manager, who acknowledged the behavior as abuse but did not immediately escalate the report to the DON. When the DON was eventually notified, an internal investigation was conducted, and the staff member involved was terminated. However, the facility did not report the allegation to the State Agency or local law enforcement, and the DON stated the decision was made not to report because the notification was delayed and they anticipated being cited for late reporting.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident with a history of mild cognitive impairment, personality disorder, delusional disorders, unspecified psychosis, and depression. On the date in question, the resident's sister contacted local law enforcement to report concerns that the resident was being abused and did not feel safe. Law enforcement arrived at the facility to address the allegation. Facility documentation showed that staff were aware of the report and notified relevant parties, including the resident's guardian, Adult Protective Services social worker, and supervisory staff. However, there was no documentation of any investigation into the abuse allegation as required by facility policy. During an interview, the Director of Nursing stated that both the resident and the resident's sister had made multiple prior unfounded allegations of abuse and, as a result, did not believe this particular allegation warranted reporting or investigation. The facility's policy requires that all reports of abuse, neglect, or mistreatment be promptly and thoroughly investigated, but this was not followed in this instance. No root cause investigation or analysis was documented for the reported allegation.
Unlicensed Staff Administered Prescription Medications
Penalty
Summary
Prescription medications for one resident were administered by a Certified Nursing Assistant (CNA), contrary to facility policy and regulatory requirements. The resident had diagnoses including anxiety disorder, depression, personality disorder, and unspecified psychosis, and had physician orders for Haloperidol Lactate and Valium. Facility documentation and interviews revealed that the CNA administered these medications using food, ice cream, and a syringe, with another staff member holding the resident's hand and the CNA holding the resident's chin to squirt the medication into the resident's mouth. This administration was performed under the direct supervision of a Registered Nurse (RN), but the CNA had not completed any medication administration training or competency evaluation. Facility policies explicitly state that only licensed nurses or nurse technicians are permitted to administer medications, and that CNAs may not administer medications except for applying topical creams to unbroken skin or providing oral care with mouthwashes. Despite this, the Director of Nursing (DON) confirmed that it was common practice for CNAs to administer medications under direct nurse supervision, without additional training or competency assessment. This practice was in direct violation of both facility policy and regulatory standards, resulting in the identified deficiency.
Failure to Provide Timely Updates on Resident Council Concerns
Penalty
Summary
The facility failed to provide timely updates to residents regarding concerns raised during resident council meetings, as required by their own policy. Specifically, three cognitively intact residents with various medical conditions, including multiple sclerosis, quadriplegia, and coronary artery disease, reported that issues such as staff discussing other residents, insufficient staffing, and long call light response times were repeatedly brought up in meetings. Despite these concerns being documented in the Resident Voice Minutes over several months, residents stated they did not receive follow-up or updates from administration or staff about actions taken to address these issues. Interviews with residents and staff revealed that the Director of Nursing did not regularly attend resident council meetings and was unaware of when they occurred. The Activity Director did not document follow-up conversations with residents, and the Case Manager confirmed there was no formal process for following up on concerns voiced in resident council. Residents expressed frustration that their concerns, particularly about staffing and call light response times, were not addressed or communicated back to them, impacting their daily routines such as timely access to breakfast and coffee.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse between residents, as evidenced by two separate incidents involving three residents. In the first incident, a resident with severe cognitive impairment and dementia (BIMS score 3/15) was involved in a verbal altercation with another resident who was cognitively intact (BIMS score 15/15) and had a history of behavioral symptoms. The cognitively intact resident was observed yelling threatening statements, while the cognitively impaired resident pushed a medication cart toward him, resulting in the latter losing balance and sustaining a bruise and abrasion after falling. In the second incident, a resident with moderate cognitive impairment and dementia (BIMS score 9/15) was found hitting the same severely cognitively impaired resident in the face. The aggressor believed the other resident was in his bed, and this event was discovered when a CNA responded to the victim's calls for help. The incident was reported to law enforcement, and the aggressor had a recent medication change that may have contributed to impulsive behavior. Both incidents were confirmed by the DON as instances of physical and verbal abuse between residents.
Failure to Conduct Thorough Investigation After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation following an alleged abuse incident involving two residents. According to the facility's policy, when an incident or suspected incident of abuse is reported, the investigation should include resident statements. In this case, a resident-to-resident altercation occurred when one resident struck another in the head with a remote after a verbal exchange. Both residents involved were cognitively intact, as indicated by their Brief Interview Mental Score (BIMS) of 15 out of 15. Law enforcement was called, and the residents were separated immediately following the incident. Despite the policy requirements, the investigation did not include interviews with other residents or further investigative steps beyond the immediate response. Staff interviews revealed that no one was instructed to interview other residents or provide additional education to staff. The DON confirmed that no further investigation was conducted, believing the event to be isolated. This lack of a comprehensive investigation did not align with the facility's policy and left the incident insufficiently examined.
Failure to Implement Care Plan for Resident Expressing Suicidal Ideation
Penalty
Summary
A deficiency occurred when staff failed to implement a resident's care plan interventions after the resident expressed suicidal ideation. The resident, who had a history of chronic suicidal ideation, mild cognitive impairment, legal blindness, abnormal gait, osteoarthritis, and anxiety disorder, repeatedly stated she wanted to kill herself. Despite these statements, Certified Nursing Assistants (CNAs) did not notify the nurse on duty or the Nurse Care Coordinator as required by the care plan. The care plan specifically directed staff not to leave the resident alone, to immediately notify nursing staff, and to provide one-to-one supervision until a nurse could assess the resident's safety and implement further interventions. On the day of the incident, the resident was found alone in her room, repeatedly calling for help and expressing a desire to die. Staff present on the unit acknowledged that the resident often made such statements and described their response as attempting to calm her and documenting the behavior, but did not escalate the situation to nursing staff for assessment. The CNAs reported that when the resident was disruptive, she was placed in her room alone to avoid agitating other residents, contrary to the care plan's instructions. There was no documentation in the progress notes of the resident's suicidal statements on the day in question, and neither the nurse on duty nor the Nurse Care Coordinator were informed of the incident. Both confirmed in interviews that they had not been notified and that the care plan should have been followed, including immediate assessment and supervision. The Director of Nursing also confirmed that the care plan's directives were not implemented as required.
Failure to Provide Non-Alarm Interventions and Proper Alarm Reduction for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that two residents at risk for falls were consistently provided with non-alarm interventions before and after the implementation of multiple alarms. Both residents were subjected to the use of several alarms simultaneously—one with five alarms and the other with four—without a documented plan to reduce alarm use or assess the necessity of concurrent alarms. The facility's own policies required that alarms be used on a short-term basis and that the interdisciplinary team review the potential for eliminating alarms while developing other strategies, but there was no evidence that these steps were followed. Additionally, alarm assessments were incomplete, with missing documentation and blank sections regarding alternative strategies and justification for alarm use. For one resident with mild cognitive impairment, legal blindness, abnormal gait, and anxiety disorder, alarms were used extensively, including a motion sensor, chair alarm, bed alarm, and a Tabs alarm. Observations revealed that the alarms were loud and disruptive, and the resident was unaware of the source of the noise. Despite the use of multiple alarms, the resident experienced several falls, some of which occurred when alarms failed to prevent self-transfers or were not in place. The care plan required the use of a gait belt for all transfers, but this was not consistently followed, and there was no documentation that nursing staff were notified when the resident refused the gait belt, as required by the care plan. For the second resident, who had dementia and a history of wandering and falls, multiple alarms were also used, including a bed alarm, chair alarm, motion sensor, and wander/elopement alarm. The care plan and assessments did not document the use of alternative interventions or a reduction plan for alarm use. There was also a lack of documentation in progress notes and social services notes regarding the discussion or justification of alarm use. Staff interviews confirmed that alarms were implemented based on the resident's history of falls, but there was no admission assessment or documentation of other options considered prior to alarm use.
Violation of Resident's Mail Privacy
Penalty
Summary
The facility failed to ensure a resident's right to privacy was maintained when receiving mail. A resident, identified as R2, who is cognitively intact and able to communicate effectively, reported that facility staff opened their mail without permission. This practice began approximately five months prior to the survey, coinciding with R2's ordering of adult movies. R2, a registered sex offender with a history of child pornography, had previously signed a waiver in 1998 allowing mail to be opened during probation, which ended in 2002. Despite the end of probation, the facility continued to open R2's mail without a current waiver or consent. Interviews with facility staff, including a Certified Nursing Assistant, Nursing Care Coordinator, and Social Services staff, confirmed the practice of opening R2's mail. The Nursing Care Coordinator stated that mail is typically delivered unopened, but R2's mail is treated differently due to their criminal history. The Director of Social Services and a Social Worker acknowledged the challenges since R2's admission and confirmed that the waiver signed during probation was no longer valid. The facility's policy on mail distribution emphasizes residents' rights to privacy and assistance with mail upon request, which was not adhered to in R2's case.
Lack of Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received a performance review every 12 months, affecting three out of five CNAs reviewed. Specifically, CNAs H, I, and J, who have been employed since 06/14/22, 07/13/17, and 08/15/22 respectively, did not have documented annual performance reviews. Upon inquiry, the Human Resources Manager confirmed that the facility did not have a system in place to conduct these reviews, and no performance reviews had been completed for any staff. This deficiency had the potential to impact all 147 residents residing in the facility.
Failure to Report Resident Altercation and Submit Investigation
Penalty
Summary
The facility failed to report an incident of potential misconduct to the state agency immediately upon learning of the incident and did not submit the required 5-day investigation report within the stipulated timeframe. This deficiency was identified during a surveyor's review of an altercation involving a resident with dementia and behavioral issues. The resident, who has a history of short-term and long-term memory problems, as well as physical and verbal behavioral symptoms, was involved in an incident where they attempted to take candy from another resident, resulting in a willful slap. This action was deemed potentially harmful and should have been reported as per the facility's policy and state regulations. The resident's care plan, which was initiated to manage psychopharmacological medication and behavior, included interventions to prevent altercations with peers. Despite these measures, the incident occurred, and the Director of Nursing acknowledged that the altercation should have been reported as it was considered willful. The failure to report the incident and submit the investigation in a timely manner highlights a lapse in adhering to the facility's abuse, neglect, mistreatment, and misappropriation of resident property policy and procedure.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide proper notification of transfer to two residents, R56 and R127, who were hospitalized. R56, who was cognitively intact and capable of making decisions, was transferred to the hospital after experiencing a fever and requesting the transfer. However, R56 was not given a written notice of the transfer, which is a requirement. During an interview, the Director of Nursing (DON) admitted that the facility does not provide written notifications to residents or their representatives when transferring them to the emergency room. Similarly, R127, who had diagnoses including paranoid schizophrenia, type 2 diabetes, dementia, and anxiety, was transferred to the hospital without receiving a written notice of the transfer. The surveyor was unable to find any documentation of a discharge/transfer notice for R127's hospitalization. When asked, the DON confirmed that the facility did not issue a transfer notice for R127's hospital transfer. This lack of proper notification is a deficiency in the facility's compliance with regulations regarding resident transfers.
Failure to Implement Care Plan for Resident with Huntington's Disease
Penalty
Summary
The facility failed to implement the comprehensive, person-centered care plan for a resident diagnosed with Huntington's disease and pneumonitis due to inhalation of food and vomit. The care plan specified that the resident required the head of the bed (HOB) to be elevated 45 degrees during and thirty minutes after tube feeding to accommodate their condition. However, during an observation by a surveyor, it was noted that the resident was positioned flat with their head resting at pillow height, contrary to the care plan's requirements. This position was not adjusted during the tube feeding administration by Registered Nurse (RN) C. Upon inquiry by the surveyor, RN C acknowledged that the bed was not at the required angle and subsequently adjusted it. Further discussions with the supervisor, RN D, and the Director of Nursing (DON) B confirmed that the expectation was for the nurse to ensure the bed was elevated to 45 degrees before starting the procedure, especially given the resident's condition that affects gastric motility and predisposes them to emesis. The failure to adhere to the care plan's directives constituted a deficiency in the care provided to the resident.
Inadequate Supervision and Safety Measures for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents, R34 and R100. R34, who has dementia and a seizure disorder, was identified as high risk for falls. Despite having a care plan that included the use of a chair sensor alarm, the facility's fall-root cause analysis revealed that the alarm was either inappropriately placed or not under the resident during two separate falls. This indicates a failure to follow the care plan and ensure the safety interventions were in place. R100, diagnosed with dementia with agitation and other behavioral issues, was supposed to have 1:1 supervision to maintain safety. However, during an incident, a new CNA, unfamiliar with R100, was unable to prevent the resident from engaging in a physical altercation with another resident. The CNA was covering for a more experienced CNA on break, and the lack of proper training and supervision led to the incident. The Director of Nursing acknowledged the expectation for the CNA to intervene before the altercation occurred, highlighting a lapse in staff training and supervision protocols.
Uncovered Food Transported to Residents' Rooms
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not covering food items during transportation to residents' rooms. The facility's policy, titled 'Dining - Meal Service,' mandates that all food must be covered when transported through the unit. However, during an observation, Certified Nursing Assistants (CNAs) were seen carrying trays with uncovered cake and drinks to residents' rooms. This occurred with three residents, who were eating in their rooms, and the uncovered items were transported down the hallway, potentially leading to contamination. The Director of Hospitality, responsible for kitchen and dining services, confirmed that all food and drinks should be covered when leaving the dining area, indicating a lapse in following the established policy.
Failure to Administer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that vaccinations were reviewed, offered, or administered for one of the sampled residents, identified as R23. The resident was admitted with severe cognitive impairment and diagnoses of chronic cough and obstructive sleep apnea. During the survey, the Infection Preventionist was unable to provide immunization information for R23, directing the surveyor to another nurse. When the surveyor followed up with Registered Nurse F, it was revealed that there was no proof that R23 had been offered or received a pneumococcal vaccine. The process for screening and administering immunizations upon admission was questioned, and RN F admitted that there was no clear process in place for residents who transferred between units. This lack of a systematic approach led to the oversight in ensuring R23 received the necessary pneumococcal vaccination, as there was no documentation or evidence of the vaccine being offered or administered. The deficiency highlights a gap in the facility's immunization protocol, particularly for residents transferring between units.
Failure to Update Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to provide care and treatment based on professional standards of practice for a resident at risk for pressure injuries. The resident, identified as R4, developed a new stage 2 pressure injury on the coccyx, which was noted on June 1, 2024, and healed by July 9, 2024. Despite the development of this pressure injury, the facility did not update R4's care plan or repositioning schedule to align with current standards of practice, which contributed to the deficiency. R4's care plan, initiated in December 2022, identified the potential for pressure ulcer development due to immobility and incontinence. However, no changes were made to the interventions following the development of the pressure injury. The care plan included interventions such as educating caregivers on skin breakdown causes, following facility protocols, and monitoring skin status. Despite these interventions, the care plan was not revised to address the new pressure injury or to adjust R4's repositioning schedule. Observations by the surveyor revealed that R4 was seated in a wheelchair for extended periods, sometimes exceeding four hours, without repositioning. The CNA responsible for R4's care was unaware of any changes to the repositioning schedule following the pressure injury's development. The Nurse Care Coordinator acknowledged that R4's care plan should have been updated to include more frequent repositioning, ideally every two hours, to prevent further pressure injuries. This oversight in care planning and execution led to the deficiency noted in the report.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to develop and implement policies and procedures for ensuring the timely reporting of a reasonable suspicion of a crime, specifically an allegation of sexual abuse. The incident involved a resident with diagnoses including congestive heart failure, anxiety disorder, major depressive disorder, type 2 diabetes, and heart failure. On 03/08/24, a family member reported to a registered nurse that the resident had alleged an Amish man was having his way with them. However, this allegation was not reported immediately as required by law. The Director of Nursing acknowledged that the report should have been made sooner, but it was not submitted to the State Agency until 03/14/24, and the police were also not notified until that date. This delay in reporting violated the requirement to report such allegations within 2 hours. The facility's policy on abuse, neglect, mistreatment, and misappropriation of resident property states that reports of abuse are to be promptly and thoroughly investigated, which was not adhered to in this case.
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Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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