Complete Care At Christian Home Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Waupun, Wisconsin.
- Location
- 452 Fox Lake Road, Waupun, Wisconsin 53963
- CMS Provider Number
- 525531
- Inspections on file
- 20
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Complete Care At Christian Home Llc during CMS and state inspections, most recent first.
Failure to Assess Wounds and Change in Condition: A resident with diabetes developed a heel blister without documented daily foot checks, a complete wound assessment, or timely MD notification, and the wound later worsened. Another resident’s toe wound was not assessed or measured on admission despite being listed in hospital paperwork. A third resident had repeated gagging and emesis with no documented assessment or provider update before hospitalization for a UTI.
A resident admitted with a cervical collar and no initial pressure injury developed an unstageable pressure injury on the back of the head from the collar. The care plan called for weekly skin checks and routine skin observation, but the record lacked documentation of skin checks under the device. Survey findings showed the wound was identified as a pressure wound from the rigid cervical collar, and RN H did not follow the wound treatment order during care, including omitting peri-wound skin prep and applying an ABD pad without an order.
The facility failed to maintain an effective infection prevention and control program after Legionella-positive water tests were found in multiple locations. Staff reported water heater temperatures were kept at 111-116°F for scalding purposes, below the level they believed was needed to kill Legionella, and acknowledged the facility lacked anti-scald protection. Despite repeat positive results, the facility did not implement the water management plan’s listed interventions for the affected resident room, and no additional testing was done to confirm the control measures were effective.
Failure to provide requested shaving assistance: A resident with Parkinson's disease, weakness, lack of coordination, and mild cognitive impairment stated a preference to be clean shaven but was observed with facial hair for three consecutive days. Care plan and task charting showed varying levels of ADL assistance, with no refusal documented. A CNA said shaving could be done daily and an LPN confirmed the resident had not been shaved, while the DON stated shaving should be offered daily.
Medication administration errors exceeded the allowed rate, with 2 errors out of 25 opportunities. An RN prepared to crush a resident’s pantoprazole DR tablet even though the medication card stated not to crush it, and another RN administered insulin lispro without priming the pen and without holding the needle in place after the injection. The facility policy and insulin pen instructions required correct administration methods, including no crushing of delayed-release medication and priming plus a post-injection hold time for insulin pens.
A resident with multiple chronic conditions experienced a significant change in condition, including increased unresponsiveness and difficulty swallowing. The assigned RN did not perform a comprehensive assessment, failed to obtain vital signs, and did not communicate detailed findings to the physician. The resident's condition worsened throughout the day, leading to hospital transfer for hypothermia and dehydration, where aggressive interventions were required.
Two residents with a history of falls did not receive adequate supervision or timely interventions to prevent further accidents, resulting in multiple unwitnessed falls and injury, including a subdural hematoma. The facility failed to complete thorough post-fall assessments, root cause analyses, and care plan updates as required by policy, with documentation and communication lapses among staff contributing to the deficiency.
A resident with cognitive impairment and a history of falls was found to have a subdural hematoma, but the facility did not complete a thorough investigation as required by policy. Staff were verbally questioned, but no written statements were obtained, and not all staff received documented training on falls prevention during the relevant period.
A resident with multiple chronic conditions did not receive adequate monitoring of fluid intake, despite being at risk for dehydration and having a documented daily fluid requirement. Staff failed to consistently track or respond to insufficient fluid intake, and the care plan did not address dehydration risk. The resident developed severe dehydration, resulting in hospitalization and subsequent decline.
A resident with multiple diagnoses experienced significant weight loss and a bleeding episode, but the facility did not promptly notify the physician as required by policy. Both nursing staff and the nurse practitioner confirmed that immediate notification was expected for these changes, but no documentation of timely notification was found.
A resident was prescribed Trazodone for sleep without a proper diagnosis of insomnia or a comprehensive sleep assessment, contrary to facility policy. Documentation of sleep issues was minimal, and there was no evidence of non-pharmacological interventions being attempted before starting the medication. The DON confirmed the lack of a structured process for sleep assessment and monitoring.
Failure to Assess Wounds and Change in Condition
Penalty
Summary
The facility did not ensure that treatment and care were provided in accordance with professional standards for residents with wounds and a change in condition. One resident with diabetes and peripheral vascular disease developed a blister on the right heel, but the record did not show daily diabetic foot checks from admission through discovery of the wound. When the heel wound was first noted, the nurse documented a blister that had peeled back and applied a dressing, but there was no complete wound assessment documented at discovery and the physician was not updated timely. The wound later required outside wound care, and the documentation showed the heel wound had enlarged and developed necrotic tissue over time. A second resident was admitted with multiple diagnoses including diabetes, acute kidney failure, heart failure, cellulitis, and atrial fibrillation. The admission skin assessment documented blisters on the right lower extremity related to cellulitis and treatment already in place, but the resident’s right big toe wound was not assessed, measured, or documented on admission. Hospital discharge paperwork showed a wound at the base of the right big toe, and the first nursing progress note mentioning the toe wound did not appear until several days later. Facility leadership stated that all wounds should be included in the initial skin assessment with measurements and treatments. A third resident had a change in condition with repeated complaints of not feeling well, gagging, and emesis. Progress notes documented the resident appearing different, tearful, spitting into a basin, and having medium emesis on more than one occasion. The record did not show vital signs for those days, and there was no documented assessment or provider update related to the episodes. The resident was hospitalized the following day after a noted change in condition and was admitted with a urinary tract infection.
Failure to Monitor Skin Under Cervical Collar Led to Unstageable Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident admitted without a pressure injury did not develop a pressure injury and failed to provide care and services consistent with professional standards to prevent the development or worsening of pressure injuries. R5 was admitted with a cervical collar and diagnoses including a displaced type 2 dens fracture, diabetes mellitus, and peripheral vascular disease. The resident was admitted without a pressure injury to the neck or back of the head, and the record showed no physician order directing staff to check the skin under or around the cervical collar. R5’s care plan identified skin integrity risks and included weekly skin checks and observation of the skin during morning and evening cares, but survey review found no documentation of skin checks under the cervical collar. On 4/8/26, the wound doctor documented an unstageable pressure injury on the head, described as a pressure wound from a rigid cervical collar at the left/middle occipital area, with thick adherent necrotic tissue and moderate sero-sanguinous drainage. The wound treatment plan ordered calcium alginate, a foam silicone border dressing, and skin prep to the peri-wound area. During observation of wound care on 4/14/26, RN H cleansed the wound, applied mepilex, and placed an ABD pad for comfort, but did not apply skin prep to the peri-wound and there was no order for the ABD pad. RN H stated staff were checking under the collar daily but were not documenting those checks and were not completing the weekly assessments. DON B stated staff should check under a device at least every shift and expected the skin under the cervical collar to be checked, while MD J stated staff should be checking the skin under the collar. The surveyor concluded that R5 developed a medical device-related pressure injury because nursing staff were not checking the skin under the cervical collar daily.
Failure to Maintain Effective Legionella Water Management Program
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. The deficiency involved the facility’s water management program after Legionella-positive test results were identified in multiple locations, including a break room sink, a shower, R22’s room sink, and other shower areas. The facility’s policy stated that a water management program was part of the infection prevention and control program, with the Maintenance Director serving as the leader, and the water management plan required validation testing and response to any Legionella-positive sample. Surveyor interview and record review showed that the facility’s water heater temperatures were maintained below the level the facility acknowledged was needed to kill Legionella. MT C stated the water heater was at 111 degrees Fahrenheit for scalding purposes and later set at 116 degrees Fahrenheit, with resident rooms ranging from 111 to 114 degrees Fahrenheit. MT C also stated the facility could not keep the water heater temperature high enough because it did not have anti-scald protection. The facility had positive Legionella results on the initial sampling and on repeat sampling, but staff stated they believed the numbers were low and did not implement the interventions listed in the water management plan’s response guidance. The surveyor also reviewed R22’s room, where the resident stated he or she washed up at the bathroom sink and used the sink for face washing and brushing teeth. DON/IP B acknowledged that water used for brushing teeth could be consumed and that there was a potential for aspiration during brushing. Despite this, the facility did not provide additional interventions for R22’s room to reduce exposure, and staff stated there was no further action beyond additional flushing. The facility also did not do additional testing to determine whether the control measures were effective after the positive Legionella findings.
Failure to Provide Requested Shaving Assistance
Penalty
Summary
The facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one resident reviewed for grooming. The resident stated a preference to be clean shaven, but was observed with facial hair over the cheeks, chin, and neck for three consecutive days. The resident had diagnoses including Parkinson's disease, weakness, lack of coordination, and mild cognitive impairment, and the MDS indicated a BIMS score of 13, showing the resident was cognitively intact. The resident's care plan identified deficits with ADLs and included hygiene assistance, and the task charting for personal hygiene showed a mix of dependent, partial/moderate assist, and substantial/maximal assist, with no documentation of refusal. During interviews, a CNA stated residents are shaved on bath days and if they request it on other days, and that the resident could be shaved daily, but was not sure it had been offered that day. An LPN stated residents are usually shaved on bath day, confirmed the resident's bath was on 4/13/26, and stated the resident had not been shaved. The DON stated shaving should be offered daily.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility did not ensure that medication error rates remained below 5 percent. Surveyors identified 2 medication errors out of 25 opportunities, affecting 2 of 8 residents observed during the medication administration task, for an error rate of 8%. The facility policy stated that medications must be administered safely and in accordance with the order, including the right resident, medication, dosage, time, and method of administration. For one resident with diagnoses including GERD and a history of peptic ulcer disease, the physician ordered pantoprazole sodium oral tablet delayed release 20 mg once daily. During observation, an RN placed seven tablets into a plastic bag to crush for administration, and one of the tablets was the resident’s pantoprazole DR. The surveyor stopped the nurse before the medication was crushed. The nurse then reviewed the medication card, saw that the pantoprazole was delayed release, and removed it from the bag after recognizing it should not be crushed. For another resident receiving insulin lispro (Humalog), the surveyor observed an RN apply a needle to the insulin pen and dial the dose to 14 units, but the nurse did not prime the pen before administration and did not keep the needle in the skin after the dose was given. The facility’s insulin pen policy required priming before each use and keeping the needle in the skin for 6 to 10 seconds after injection. The surveyor reviewed the manufacturer’s instructions with the nurse, and the DON stated that insulin pens need to be primed prior to setting the dose and the needle must remain in place for at least 10 seconds after administration.
Failure to Assess and Respond to Resident's Change in Condition
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to provide appropriate assessment and care for a resident who exhibited a significant change in condition. The resident, who had a history of Parkinson's disease, anemia, hyponatremia, chronic kidney disease, congestive heart failure, and hypertension, was noted by staff and family to be less responsive, exhibiting increased shaking, drooling, and difficulty swallowing. Despite these changes, the RN did not perform a comprehensive assessment, did not obtain vital signs, and did not provide a detailed report to the physician. The only action taken was to verbally notify the Director of Nursing (DON) and request that the physician look at the resident, which resulted in lab work being ordered for the following day. There was no documentation of a thorough assessment or timely communication of the resident's deteriorating condition to the physician. Throughout the day, the resident's condition continued to decline. Certified Nursing Assistants (CNAs) and other nursing staff observed that the resident was unable to eat or swallow, was minimally responsive, and required more assistance with transfers than usual. The second shift nurse, upon being informed of the resident's status, performed an assessment, obtained vital signs, and found the resident to have a low oxygen saturation. The resident was subsequently placed on supplemental oxygen and transferred to the emergency department, where he was found to be unresponsive, hypothermic, dehydrated, and suffering from multiple abnormal lab values. The emergency department initiated aggressive warming and hydration measures, and the resident was admitted for comfort care. Interviews with facility staff confirmed that the RN on the day shift did not follow professional standards of practice as outlined in the Wisconsin Nurse Practice Act and facility expectations. The DON and physician both stated that the expectation was for the nurse to assess the resident, obtain vital signs, and communicate findings to the physician. The RN admitted to not completing an assessment or obtaining vital signs, and documentation was not completed in a timely manner. The facility was unable to provide a change in condition policy when requested by the surveyor.
Failure to Provide Adequate Supervision and Fall Prevention for Residents at Risk
Penalty
Summary
The facility failed to ensure that residents at risk for falls received adequate supervision and timely, appropriate interventions to prevent accidents. Two residents with a history of falls experienced multiple unwitnessed falls, with one resident suffering a subdural hematoma. Despite repeated incidents, the facility did not complete thorough post-fall assessments, root cause analyses, or timely updates to care plans. Documentation was often incomplete, with missing or partially filled vital signs and neurological check sheets, and post-fall assessments were sometimes delayed by weeks. For one resident with cognitive impairment, lymphedema, atrial fibrillation, and a history of repeated falls, there were seven unwitnessed falls while self-transferring. The facility did not conduct immediate or comprehensive assessments after these falls, nor did it update the resident's care plan with new interventions. The interdisciplinary team (IDT) reviews and root cause analyses were either not completed or significantly delayed, and care plan updates were not made to reflect new risks or interventions. Staff interviews confirmed that care plans were not consistently updated after falls, and that communication lapses contributed to the lack of timely intervention. Another resident, identified as at risk for falls upon admission, experienced eight falls without the facility identifying root causes, trends, or updating the care plan accordingly. Facility policies required comprehensive post-fall assessments, care plan reviews, and implementation of individualized interventions, but these were not followed. Staff interviews revealed inconsistent understanding and execution of fall prevention protocols, and documentation did not reflect the required monitoring or follow-up after falls.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for one resident who was found to have a subdural hematoma. According to the facility's policy, all unexplained injuries, including those of unknown source, must be investigated, even if the resident is discharged or the injury is discovered after discharge. The resident in question had a history of cognitive impairment, repeated falls, difficulty walking, and muscle wasting. The facility became aware of the subdural hematoma but did not obtain written statements from staff as part of the investigation, despite this being an expected component of a thorough inquiry. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that while staff were verbally questioned about the incident, no written documentation of their statements was collected. The NHA acknowledged that staff statements are a required part of the investigation process. Additionally, although some staff received education on falls prevention as part of a process improvement project, not all staff who worked during the relevant period had completed the training, and there was no documentation for the remaining staff. This incomplete investigation did not meet the facility's own policy requirements for responding to injuries of unknown origin.
Failure to Monitor and Maintain Adequate Hydration Leading to Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, specifically regarding hydration. The resident, who had multiple diagnoses including Parkinson's disease, anemia, hypo-osmolality, hyponatremia, chronic kidney disease, congestive heart failure, and hypertension, was assessed to require 2,350 cc of fluids per day. Despite this, fluid intake records showed that the resident consistently received less than the estimated daily fluid needs on nearly all documented days, with only one day meeting the requirement. The care plan did not address the resident's risk for dehydration, and there was no evidence of a dehydration assessment, comprehensive RN assessment, or provider notification when fluid goals were not met. Staff interviews revealed a lack of clarity and responsibility regarding monitoring fluid intake for residents not on fluid restrictions. The RN stated that fluid intake was only monitored for residents on fluid restrictions, and was unaware of how to identify residents at risk for dehydration through care plans or Kardex. The DON indicated that all residents are at risk for dehydration but was unsure who was responsible for ensuring fluid goals were met, suggesting the dietician was responsible but also expressing uncertainty about the process. There was no documentation that the dietary manager or registered dietitian was notified when the resident failed to meet fluid needs over multiple days. The resident experienced a significant change in condition, including altered mental status, lethargy, increased confusion, increased shaking, and weakness, leading to hospitalization. Emergency department records documented the resident as unresponsive, hypothermic, and dehydrated, with abnormal laboratory values indicating dehydration and renal impairment. The resident was treated with IV fluids and admitted to the hospital, later returning to the facility on hospice care and subsequently passing away. The failure to monitor and address the resident's hydration status directly resulted in hospitalization for dehydration.
Failure to Timely Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify and consult with a resident's physician when there was a significant change in condition for one resident. Specifically, the facility did not report a significant weight loss in a timely manner to the resident's provider. The resident, who had diagnoses including vascular dementia, depression, and dysphagia, experienced a weight drop from 222.4 pounds to 196.8 pounds over a period of approximately three weeks. Both the RN and DON confirmed that such a weight loss was significant and required physician notification, but no documentation of such notification was provided. The nurse practitioner also confirmed that notification was expected and had not occurred. Additionally, the facility did not notify the physician immediately when the same resident experienced a large incontinent bowel movement with moderate to large amounts of blood. The incident was documented in the progress notes, and the resident was later sent to the hospital for evaluation. However, both the RN and DON acknowledged that the physician should have been notified at the time the bleeding was first observed in the morning, but this did not occur. The nurse practitioner confirmed that immediate notification was expected in such cases. The facility's own policies require prompt notification of the physician and resident representative in the event of acute illness or significant changes in the resident's condition, including weight changes and bleeding episodes. Despite these policies, the required notifications were not made or documented for the resident's significant weight loss and bleeding event.
Failure to Ensure Medication Regimen Free from Unnecessary Drugs Due to Inadequate Sleep Assessment
Penalty
Summary
The facility failed to ensure that a resident’s medication regimen was free from unnecessary drugs, specifically by administering an antidepressant, Trazodone, for sleep without an appropriate diagnosis or adequate assessment. The resident, who had multiple diagnoses including dementia, Wernicke's encephalopathy, and alcohol dependence, was prescribed Trazodone for sleep despite lacking a documented diagnosis of insomnia. The only sleep assessment available was part of an admission tool, which noted some sleep difficulties but did not constitute a comprehensive evaluation or establish a clinical indication for the medication. There was no evidence of a formal sleep assessment or documentation of non-pharmacological interventions prior to starting the medication, as required by facility policy. Further review of the resident’s records showed minimal documentation of sleep issues, with insomnia only marked once in the behavior monitoring report. Progress notes and physician notifications referenced sleep difficulties and restlessness, but there was no consistent or detailed tracking of sleep patterns or hours. The DON acknowledged the absence of a structured process for sleep assessment and monitoring, and confirmed that sleep diaries were not used. The facility’s approach did not align with its own policy, which requires thorough documentation of indications for psychotropic medications and the use of non-pharmacological interventions before initiating such drugs.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
