Complete Care At Glendale West
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, Wisconsin.
- Location
- 6263 N Green Bay Ave, Glendale, Wisconsin 53209
- CMS Provider Number
- 525547
- Inspections on file
- 28
- Latest survey
- November 12, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Complete Care At Glendale West during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a cognitively intact status was observed with a medication cup containing Tylenol left on the overbed table for self-administration, despite no interdisciplinary team assessment or documentation authorizing self-administration. Staff were unable to provide evidence of the required assessment, and facility policy was not followed.
Three residents dependent on staff for ADLs did not consistently receive scheduled showers, with some only receiving bed baths due to lack of appropriate equipment and incomplete documentation. Staff and leadership confirmed that alternative bathing methods were not provided, and care plans were not updated to reflect actual practices.
A resident with chronic Foley catheter use and hypertension experienced a significant change in condition, including increased pain and lack of urine output, but did not receive timely assessment, documentation, or intervention as required by physician orders and facility policy. Staff failed to document vital signs, pain characteristics, and changes in urinary output, and did not perform a comprehensive evaluation despite clear signs of distress. The resident was later hospitalized with sepsis and acute renal failure due to urinary obstruction.
Staff failed to follow infection control protocols for a resident on enhanced barrier precautions, including not wearing gowns during high-contact care, improper hand hygiene, and allowing a urinary collection bag to rest on the floor. The resident, who required substantial assistance and had an indwelling urinary catheter, was cared for by staff who did not consistently change gloves or wash hands between tasks, increasing the risk of infection transmission.
Several residents were repeatedly observed in gowns rather than regular clothing, both in their rooms and in common areas, despite expressing a preference to be dressed and reporting discomfort. Staff interviews revealed that residents without available clothes were routinely left in gowns, even though donated clothing was available in the facility. The facility did not consistently accommodate residents' preferences for clothing, resulting in a lack of dignity and respect for their individual needs.
Several residents were not provided with or did not sign admission agreements—including consent for treatment, financial information, and resident rights—within a reasonable timeframe. In some cases, residents were discharged or readmitted before receiving this information, and one resident reported missing money without having been informed of the facility's policies for safeguarding belongings. Admissions staff confirmed that there was no set timeline for reviewing these agreements, leading to delays in informing residents of their rights and responsibilities.
Multiple residents were admitted or readmitted without timely completion of baseline care plans, and there was no documentation that these plans were reviewed with the residents or that copies were provided. Staff interviews revealed confusion about the process and timing for care plan development and review, and residents reported not receiving or reviewing their plans of care.
A resident receiving an antidepressant was not comprehensively assessed for medication use, as required by facility policy. Documentation failed to include specific symptoms of depression, indicators for use, or non-pharmacological interventions. Staff interviews confirmed that comprehensive assessments were not completed, and care plans only addressed monitoring for side effects rather than the clinical rationale for the medication.
A resident admitted with depression and prescribed daily Prozac did not receive a comprehensive assessment of depression or mood symptoms during admission and significant change in status MDS assessments. Key assessment questions were omitted, and the Care Area Assessments failed to document specific symptoms or non-pharmacological interventions. Medication reviews and care planning did not address or monitor the resident's indications for antidepressant use.
Surveyors found that two residents were not properly screened for serious mental disorders or intellectual disabilities as required by PASARR regulations. One resident did not have a follow-up PASARR Level 1 submitted after a 30-day hospital exemption expired, and another resident's PASARR Level 1 failed to document diagnoses of anxiety disorder and unspecified psychosis, which would have triggered a Level 2 evaluation.
A resident with legal blindness and optic atrophy did not receive timely optometry services after a missed appointment was not rescheduled, despite an active request and care plan interventions. The facility lacked a system to track missed or canceled vision visits, resulting in a lapse in care and staff being unaware of the resident's ongoing vision concerns.
A resident with a history of dysphagia, hemiplegia, and other medical conditions was not provided with the required 1:1 supervision during meals, as ordered by the physician. Despite facility policy and documentation indicating the need for close monitoring, staff were observed leaving the resident unsupervised during several meals, and key team members were unaware of the supervision requirements. This lack of adherence to orders and communication among staff resulted in a deficiency related to accident prevention and resident safety.
A resident scheduled for dialysis received incorrect medication administration from an LPN, including an initially incorrect insulin dose, only one capsule each of Vitamin D and Docusate instead of two, and omission of Pantoprazole and Thiamine. The LPN acknowledged the errors, which resulted in a medication error rate of 16.67 percent, exceeding the acceptable threshold.
Staff did not follow infection control protocols for a resident on Enhanced Barrier Precautions, as both an LPN and a CNA performed high-contact care activities, including tube feeding and catheter care, without wearing gowns as required by facility policy. The resident had multiple medical conditions necessitating these precautions, and the lapses were observed despite clear signage and documented care plans.
Surveyors found that the facility did not create complete care plans for several residents on antidepressant medications, omitting individualized goals, symptoms, and non-pharmacological interventions for depression. Additionally, a resident with documented bladder incontinence did not have a care plan addressing this need. Staff interviews confirmed these omissions, and there was no evidence that adverse medication effects were reported to a physician as required.
A resident with atrial fibrillation was admitted with hospital orders for Apixaban 5 mg twice daily, but due to a transcription error by the ADON, the medication was entered as once daily in the MAR. The facility physician signed the incorrect order without documentation of awareness of the original dosage, and there was no evidence that the POA was notified of the change. The resident received half the prescribed dose for over a month, with no documented secondary review or reconciliation against the hospital discharge summary.
A resident admitted with multiple pressure injuries did not receive a comprehensive skin assessment with measurements and detailed documentation upon admission, as required by facility policy. Wound care treatments were not consistently documented as completed in the TAR for several days, and a full assessment was delayed by three days. Handwritten wound logs provided after surveyor inquiry were not part of the formal medical record and lacked essential details, resulting in incomplete and delayed documentation of the resident's condition.
Several residents reported being served undercooked chicken, with red juices contaminating other foods on their plates. Despite complaints from cognitively intact residents, there was no formal investigation to determine the cause or extent of the issue. The Dietary Manager was not present on the day of the incident, and the Nursing Home Administrator concluded only one resident had a concern after informal discussions, without processing the incident through the grievance system.
The facility failed to properly address grievances from two residents. One resident reported being served undercooked chicken, but no grievance form was initiated, and no follow-up occurred. Another resident's family member raised concerns about laundry handling and meal services, but did not receive written responses, contrary to facility policy. The facility's grievance process was not followed, leading to unresolved issues and dissatisfaction.
The facility failed to serve food at the appropriate temperature, affecting two residents who reported their meals were not hot enough. The Dietary Manager confirmed the BBQ rib patty was lukewarm and used an infrared thermometer, which read 125 degrees, below the required 135 degrees. A malfunction in the steam table was later discovered, contributing to the issue.
A resident with a history of stroke and chronic pain was left without Oxycodone for several days due to a failure in communication and documentation between the LTC facility, pharmacy, and physician. The resident relied on less effective APAP for pain relief, as the facility did not ensure a timely renewal of the prescription. The deficiency was marked by assumptions and lack of follow-up, leading to inadequate pain management.
Two residents reported receiving cold food and beverages, which were not palatable when reheated. The facility's grievance log documented ongoing concerns, and observations revealed inadequate food coverage and temperatures below acceptable levels. The Dietary Manager acknowledged potential issues with food cart usage, and the DON confirmed the temperatures did not meet facility standards.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was properly assessed by the interdisciplinary team to determine if it was clinically appropriate for the resident to self-administer medication. The facility's policy requires that residents may only self-administer medications after an interdisciplinary team assessment and documentation of the resident's preference. However, a surveyor observed a medication cup labeled with the resident's name and containing two white tablets (Tylenol) left on the overbed table. The resident, who has diagnoses including hypertension, lumbar radiculopathy, osteoarthritis, benign prostatic hyperplasia, obstructive and reflux uropathy, and anxiety disorder, was found to be cognitively intact with a BIMS score of 15. The resident stated that he sometimes takes the medication himself, indicating that self-administration was occurring without the required assessment. Further review of the resident's medical record and medication administration record revealed no documentation of a self-administration assessment. Staff, including an LPN and the DON, were unable to locate such an assessment, and the LPN later acknowledged that the resident was not authorized to self-administer medication. The facility's own policy and assessment forms indicated that the resident had not expressed a desire to self-administer medications, yet the medication was left at the bedside for self-administration without proper authorization or assessment.
Failure to Provide Scheduled Showers and Adequate Bathing Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide showers as required for three residents who were dependent on staff for activities of daily living (ADLs), specifically bathing. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain personal hygiene, including scheduled showers or alternative bathing methods. However, documentation and staff interviews revealed that these residents did not consistently receive showers as scheduled, and in some cases, only bed baths were provided without documented alternatives or clear communication in care plans. One resident with hemiplegia, hemiparesis, seizures, and dementia was completely dependent on staff for all care, including bathing. Despite care plans and physician orders specifying scheduled showers, the resident only received bed baths due to poor trunk control and lack of appropriate equipment, such as a shower cot. The facility did not provide alternative bathing methods or update care documentation to reflect the resident's actual bathing routine. Bathing records showed multiple missed scheduled bathings, with the resident sometimes going up to ten days without a bath. Another resident, cognitively intact but requiring maximum assistance for bathing, was scheduled for showers twice weekly. However, review of records and staff interviews indicated that showers were often not provided as scheduled, particularly on certain days when staff expressed reluctance or cited the absence of therapy staff. The third resident, with multiple chronic conditions and mobility impairments, was also scheduled for showers twice weekly but reportedly never received a shower since admission due to lack of appropriately sized equipment. Staff documented showers in records despite only providing bed baths, and the resident reported never having their hair washed by staff. Facility leadership and staff confirmed the lack of appropriate equipment and the absence of consistent documentation or alternative bathing arrangements.
Failure to Assess and Document Change in Condition Leading to Hospitalization
Penalty
Summary
A resident with multiple chronic conditions, including hypertension, chronic Foley catheter use, and a history of urinary retention, did not receive assessment, treatment, and care in accordance with professional standards of practice following a change in condition. The resident experienced increased pain, rated at 8 out of 10, and received PRN Oxycodone during the night shift for the first time at this pain level. Despite physician orders requiring daily vital signs due to hypertension and specific documentation of pain characteristics with each PRN pain medication administration, there was no documented assessment of the cause of pain, vital signs, or pain characteristics at the time of administration. The medication administration record was blank for the required pain flow sheet documentation, and vital signs were not recorded as ordered, with the last documented set occurring nearly two weeks prior to the incident. Certified Nursing Assistants (CNAs) and nursing staff observed and reported that the resident was not feeling well, appeared unwell, and had no urine output in the urinary collection bag on the morning of the incident. The resident reported symptoms such as a hard abdomen and foul-smelling urine to both CNAs and nursing staff, but these concerns were not adequately assessed or documented. Interviews revealed that staff either did not recall or did not perform a full assessment, and there was no evidence of a comprehensive evaluation or documentation of the resident's change in condition prior to the resident being sent to a scheduled medical appointment. The facility's policy required baseline assessments and documentation for acute changes in condition, which were not followed. Upon arrival at the physician's office, the resident was found to have an empty urinary collection bag and was subsequently transferred to the emergency department, where he was diagnosed with sepsis, acute renal failure, and septic shock due to urinary obstruction from a clogged Foley catheter. Hospital records confirmed that the resident had experienced lower abdominal pain and lack of urine output for at least two days prior to admission. The lack of timely assessment, documentation, and intervention by facility staff in response to the resident's change in condition and physician orders led to a significant health decline requiring ICU admission.
Failure to Follow Infection Control Protocols During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in hand hygiene, improper use of personal protective equipment (PPE), and inappropriate handling of a urinary collection bag for a resident on enhanced barrier precautions. During incontinence care, a Licensed Practical Nurse (LPN) was observed wearing only gloves, without a gown, while providing care to a resident with an indwelling urinary catheter and enhanced barrier precautions in place. The LPN also handled the resident’s urinary collection bag, which was found lying directly on the floor and partially under the bed’s stabilizing section, contrary to facility policy and CDC guidelines. The LPN did not perform hand hygiene before leaving the resident’s room after completing care tasks. Further observations revealed that a Certified Nursing Assistant (CNA) failed to remove gloves and perform hand hygiene after blowing her nose and after providing perineal care involving exposure to fecal matter. The CNA continued to perform additional care tasks, such as applying cream and repositioning the resident, without changing gloves or washing hands. Both the LPN and CNA did not consistently follow the facility’s policies regarding hand hygiene and the use of gowns and gloves during high-contact care activities for residents on enhanced barrier precautions. The resident involved had multiple medical conditions, including hypertension, lumbar radiculopathy, osteoarthritis, benign prostatic hyperplasia, obstructive and reflux uropathy, and anxiety disorder. The resident required substantial assistance with toileting and hygiene and had an indwelling urinary catheter, necessitating enhanced barrier precautions. Despite clear facility policies and physician orders for the use of gowns and gloves during high-contact care, staff did not adhere to these protocols, resulting in a failure to reduce the risk of disease and infection transmission.
Failure to Honor Resident Dignity and Clothing Preferences
Penalty
Summary
Surveyors found that the facility failed to ensure residents were treated with dignity and respect, specifically regarding their preference to be dressed in regular clothing rather than gowns. Multiple residents were observed over several days in gowns, both in their rooms and in common areas such as hallways and the dining room. Interviews with these residents revealed that they preferred to be dressed in clothes, with some expressing discomfort and stating they were cold in gowns. Residents also reported that they had communicated their preferences to staff, but their requests were not consistently honored. The facility's own policy requires staff to make reasonable accommodations for residents' needs and preferences, including assistance with dressing. Despite this, staff interviews indicated that if residents did not have clothes available, they were simply dressed in gowns. Staff acknowledged the existence of donated clothing in the facility's laundry, but there was a lack of consistent communication and follow-through to ensure residents had access to appropriate clothing. Some staff stated they would only provide clothes if informed by other departments, and there was no systematic process to ensure residents' closets were stocked with clothing. The affected residents had varying levels of cognitive and physical impairment, with some requiring substantial assistance for dressing and expressing that choosing their own clothes was important to them. Observations showed that residents' personal grooming and hygiene were also neglected, as evidenced by disheveled hair and unshaven faces. The deficiency persisted until family members intervened or until the last day of the survey, when residents were finally observed dressed in regular clothing.
Failure to Timely Inform Residents of Rights, Services, and Financial Information Upon Admission
Penalty
Summary
The facility failed to ensure that four residents were fully informed of their rights, rules, services, charges, and required financial information prior to or upon admission. Specifically, these residents did not receive or sign the admission agreement, which includes consent for treatment, financial agreements, and resident rights and responsibilities, within a reasonable timeframe. In several cases, the admission agreement was not acknowledged until days or weeks after admission, and in some instances, not at all before discharge. For example, one resident was admitted and discharged without ever signing the admission agreement or being informed of the facility's policies regarding safeguarding personal belongings. This resident later reported missing a significant amount of money, and there was no documentation that the facility had reviewed options or restrictions for safeguarding possessions with the resident. Other residents experienced similar delays, with admission agreements not reviewed or signed until well after admission, and in some cases, only after a second admission to the facility. Interviews with admissions staff revealed that there was no specific timeline for reviewing the admission agreement with residents, and it was common for the process to be delayed by several days. The facility's own policies require that residents be provided with information about services, rights, and financial matters prior to or upon admission, but these procedures were not consistently followed. As a result, residents were not fully informed of their rights, financial options, or consent for treatment in a timely manner.
Failure to Timely Develop and Review Baseline Care Plans with Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for multiple residents, as required by policy. Several residents, including those with complex medical conditions such as congestive heart failure, diabetes, and end-stage renal disease, were admitted or readmitted to the facility, but their baseline care plans were either not completed within the required timeframe or lacked documentation that the plans were reviewed with the residents or their representatives. In some cases, baseline care plans were signed by staff several days after admission, and there was no evidence that residents received a copy of their care plan or participated in its review. Interviews with residents revealed that they did not recall receiving a plan of care or any related documentation, and some stated they had never received such information during multiple admissions. Record reviews confirmed the absence of documentation showing that baseline care plans were provided to or reviewed with the residents. Additionally, care plan meetings were held, but there was no documentation that the plans of care were discussed with the residents during these meetings. Staff interviews indicated a lack of clarity regarding the process and timing for completing and reviewing baseline care plans. Nursing managers and social workers acknowledged that baseline care plans were typically reviewed with residents at the first care conference, which often occurred after the 48-hour window. Documentation of resident receipt and review of the care plan was inconsistent or missing, and staff admitted that signatures from residents or their representatives were not routinely obtained or documented.
Lack of Comprehensive Assessment for Antidepressant Use
Penalty
Summary
A deficiency was identified when a resident admitted with diagnoses of depression and stroke was prescribed an antidepressant medication (Prozac) without a comprehensive assessment for its use. The facility's policy requires documentation of clinical rationale, including assessment of the resident's condition, therapeutic goals, and consideration of non-pharmacological interventions before administering psychotropic medications. However, the resident's medical record, care plans, and medication review forms lacked documentation of specific symptoms of depression, indicators for use, and non-pharmacological interventions. The Care Area Assessments (CAAs) completed by the MDS RN only noted the medication was for depression but did not detail the resident's symptoms or alternative interventions attempted. Interviews with facility staff, including the Unit Manager and Social Worker, confirmed that comprehensive assessments for psychotropic medication use were not completed, and they did not document symptoms or non-pharmacological approaches. Medication reviews and care plans focused on monitoring side effects but did not provide evidence supporting the need for the antidepressant or describe behavioral symptoms and their frequency. Even after the resident declined formal psychological services, there was no plan of care established to monitor or address the indications for antidepressant use.
Failure to Complete Comprehensive Depression Assessment and Care Planning for Antidepressant Use
Penalty
Summary
The facility failed to conduct a comprehensive assessment of depression and mood for a resident who was admitted with diagnoses of depression and stroke and prescribed daily Prozac. Upon admission and during a significant change in status, the Minimum Data Set (MDS) assessments did not fully evaluate the resident's depression or mood symptoms, omitting key questions and resulting in incomplete severity scoring. The Care Area Assessments (CAA) for psychotropic drug use documented the use of Prozac but did not include the resident's specific symptoms or any non-pharmacological interventions. Interviews with the MDS Registered Nurse and Social Worker revealed that they only coded the medication and did not assess or document the symptoms or comprehensive needs related to the antidepressant use. Further review of medication records and care conference notes showed that medication reviews lacked documentation of behaviors, their frequency, and non-pharmacological interventions for depression. The care plan did not address or monitor the indications for antidepressant use or interventions, despite the resident declining formal psychological services. A late entry PHQ-9 assessment was submitted, but there was no evidence it contributed to accurate MDS assessments or care planning for the resident's antidepressant therapy.
Failure to Complete Accurate and Timely PASARR Screenings
Penalty
Summary
The facility failed to ensure accurate and timely PASARR (Preadmission Screening and Resident Review) screenings for residents with potential mental disorders or intellectual disabilities. For one resident, a PASARR Level 1 screen was completed prior to admission and a 30-day hospital exemption was documented, which allowed admission without a Level 2 screen. However, after the resident remained in the facility beyond the 30-day exemption period, the facility did not resubmit a PASARR Level 1 as required. The Nursing Home Administrator confirmed that a follow-up PASARR was not completed prior to the expiration of the exemption, despite the resident having diagnoses of dementia and unspecified psychosis and being prescribed antipsychotic and antianxiety medications. For another resident, the facility failed to accurately document the presence of a serious mental illness on the PASARR Level 1 screen. The resident was admitted with diagnoses including anxiety disorder and unspecified psychosis, both of which are considered major mental disorders under DSM-5 criteria. Despite this, the PASARR Level 1 indicated that the resident did not have a major mental disorder, which prevented the initiation of a Level 2 PASARR evaluation. The Nursing Home Administrator stated that the answer was marked "NO" because there was no diagnosis to substantiate a "YES," even though the resident's medical record included relevant diagnoses. These deficiencies were identified through interview and record review by surveyors, who noted that the facility's practices did not align with its own policy and state requirements for PASARR screening. The lack of accurate and timely PASARR assessments resulted in residents not being properly evaluated for serious mental illness or intellectual disability as required.
Failure to Ensure Timely Vision Services for Resident with Legal Blindness
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of legal blindness and optic atrophy did not receive timely and appropriate vision care services. The resident had not been seen by an optometrist since a missed appointment, and the missed visit was never rescheduled despite an active request and signed consent for vision care. The resident's care plan included interventions such as arranging consultations with an eye care practitioner and monitoring for acute eye problems, but these interventions were not effectively implemented. Record review and interviews revealed that the process for scheduling vision appointments relied on the resident's request and consent, after which the resident would be placed on a list for quarterly visits by an external provider. However, after the resident missed a scheduled visit due to being in bed, there was no follow-up to ensure the resident remained on the provider's list or to reschedule the appointment. The facility lacked a tracking mechanism to monitor whether visits occurred, were missed, or canceled, and there was no system to identify if a resident was no longer receiving services. The resident reported ongoing vision issues and expressed a desire for a vision appointment, but staff were unaware of the lapse in care and did not inform the resident of any upcoming appointments. Interviews with staff indicated uncertainty about responsibility for tracking missed or discontinued services, and there was no documentation or system in place to ensure continuity of vision care for the resident.
Failure to Provide Required 1:1 Supervision During Meals for Resident with Swallowing Difficulties
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure safety to prevent accidents for a resident with significant swallowing difficulties and other complex medical conditions. The resident had physician orders for 1:1 supervision during all meals due to a history of dysphagia, hemiplegia, and other health issues that increased the risk of choking and aspiration. Despite these orders, multiple surveyor observations documented that the resident was left unsupervised during several meals, with staff either delivering trays and leaving or only providing setup assistance without remaining present for supervision. The facility's own policies required identification of hazards, implementation of interventions, and monitoring for effectiveness, including providing supervision as an intervention to mitigate accident risk. However, the resident's care card and comprehensive care plan were not updated to reflect the physician's order for 1:1 supervision, and there was confusion among staff, including the speech-language pathologist and dietitian, regarding the resident's required level of supervision. Interviews revealed that key staff members were unaware of the current physician orders, and documentation in the Treatment Administration Record indicated staff were signing off on supervision that was not actually being provided. Surveyor interviews and observations further highlighted a lack of communication and coordination among the interdisciplinary team regarding the resident's dietary and safety needs. The speech-language pathologist was not aware of the 1:1 supervision order, and the dietitian could not recall reviewing the relevant hospital paperwork or physician orders. The resident was observed eating without supervision on multiple occasions, contrary to the documented orders and facility policy, leading to the identified deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent, as required by policy, resulting in a medication error rate of 16.67 percent during the observed medication pass. During the observation, an LPN was seen preparing and administering medications to a resident who had a blood sugar of 216 and was scheduled to go to dialysis. The LPN initially drew up the incorrect dose of 70/30 insulin (5 units instead of the ordered 3 units) but corrected the dose before administration after the error was noticed. Additionally, the LPN administered only one capsule each of Vitamin D and Docusate, despite orders for two capsules of each, and omitted administration of Pantoprazole Sodium and Thiamine, both of which were ordered for the resident at that time. Upon interview, the LPN acknowledged the errors, attributing them to being flustered by the resident's presence at the medication cart and the urgency of the resident needing to leave for dialysis. The LPN confirmed that only one capsule each of Vitamin D and Docusate was given, and that Pantoprazole and Thiamine were not administered as ordered. The surveyor confirmed these omissions and incorrect dosages through observation and review of the medication administration records and physician orders.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow established infection prevention and control protocols for a resident who required Enhanced Barrier Precautions (EBP) due to multiple medical conditions, including a cerebral aneurysm, hemiplegia, dysarthria, and a dysfunctional bladder. The resident's care plan and facility policy required staff to wear gowns and gloves during high-contact care activities, such as tube feeding and catheter care, to prevent the transmission of multidrug-resistant organisms (MDROs). Despite clear signage and documented requirements, staff were observed performing these high-contact activities without donning gowns. Specifically, a nurse was seen changing the resident's tube feeding without a gown, and a CNA handled the resident's catheter bag and privacy cover without appropriate PPE. The Assistant Director of Nursing was present during one of these incidents and acknowledged the lapse, subsequently educating the staff involved. The deficiency was identified through direct observation, interviews, and review of the resident's records, which confirmed that the required infection control measures were not consistently implemented during resident care.
Failure to Develop Comprehensive Care Plans for Depression and Bladder Incontinence
Penalty
Summary
Surveyors identified that the facility failed to develop comprehensive care plans for residents prescribed antidepressant medications and for a resident with bladder incontinence. For two residents admitted on antidepressant medications, the care plans did not address the underlying depression diagnosis, lacked documentation of specific symptoms, and omitted non-pharmacological interventions. The care plans focused only on monitoring medication side effects, without including individualized goals or interventions for depression itself. Interviews with facility staff confirmed that care plans were not comprehensive and that staff did not routinely assess or document symptoms related to depression. Additionally, for one resident with a diagnosis of depression and documented occasional bladder incontinence, the care plan did not include any interventions or goals related to bladder care, despite this being noted in the resident's Minimum Data Set (MDS) assessment. Staff responsible for reviewing and updating care plans were unable to provide explanations for the omissions or recall relevant details about the resident's care needs. The lack of a bladder care plan was confirmed during interviews and review of the resident's records. The survey also found that, for one resident, adverse effects from depression medication were documented on several dates, but there was no evidence that these effects were reported to a physician as required by the care plan. The facility did not provide additional information or documentation to explain why the care plan interventions were not followed or why comprehensive care plans were not developed for the residents in question.
Medication Transcription Error Resulted in Incorrect Anticoagulant Dosing
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility with hospital discharge orders for Apixaban 5 mg to be administered twice daily, once in the morning and once at bedtime, for atrial fibrillation. The Assistant Director of Nursing (ADON) transcribed the order incorrectly into the facility's Medication Administration Record (MAR) as Apixaban 5 mg once daily, resulting in the resident receiving only half the prescribed dose for 34 days. The facility physician signed off on the transcribed order without documentation indicating awareness of the original hospital order or an intentional change in dosage. There was also no documentation that the resident's Power of Attorney (POA) was notified of the change in medication dosage. Interviews with facility staff revealed that the process for entering and double-checking new admission orders lacked documentation of a secondary review. The Unit Manager Registered Nurse (UMRN) confirmed that while orders were supposed to be double-checked by another administrative nurse, there was no place in the electronic medical record to document this verification. The ADON acknowledged the error in transcription and stated that the order should have been entered as twice daily, as per the hospital discharge summary. Further review of physician progress notes and interviews indicated that the physician reviewed and reconciled the medication list as it appeared in the facility's MAR, which already contained the transcription error. There was no evidence that the physician compared the facility's orders to the hospital discharge summary or that any intentional change to the Apixaban dosage was made. As a result, the resident received an incorrect dose of a critical anticoagulant medication throughout their stay.
Incomplete and Delayed Wound Documentation for Resident with Multiple Pressure Injuries
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete, accurately documented, and readily accessible, as required by facility policy and professional standards. Upon admission, the resident, who had a history of encephalopathy, diabetes, dementia, and rheumatoid arthritis, presented with multiple pressure injuries, including a Stage 4 pressure injury, several unstageable wounds, and deep tissue injuries. Although the facility's policy required a comprehensive skin assessment with measurements and detailed documentation upon admission, the initial assessment lacked critical information such as wound measurements, staging, etiology, and detailed descriptions. Additionally, the documentation did not specify the number or precise locations of wounds on the toes and feet. Treatment orders for the resident's wounds were not consistently documented as completed in the Treatment Administration Record (TAR) for several days following admission. Specifically, wound care orders for the right lower extremity, coccyx, right hip, and left foot and toes were not signed out as completed on multiple dates. The comprehensive assessment of the resident's pressure injuries was not performed until three days after admission, contrary to facility policy and expectations for timely assessment and documentation. The lack of timely and complete documentation hindered the ability to track wound progression and ensure appropriate care. When concerns were raised by the surveyor, the facility provided handwritten wound logs and assessment forms that were not part of the formal medical record and lacked essential information such as the identity of the person documenting and specific dates. These documents were only submitted after the surveyor's inquiry and were not originally included in the resident's official medical record. The incomplete and delayed documentation, as well as the absence of required information in the medical record, constituted a failure to safeguard resident-identifiable information and maintain accurate medical records in accordance with accepted professional standards.
Undercooked Chicken Served to Residents
Penalty
Summary
The facility failed to ensure that foods were prepared in a way that prevented the risk of foodborne illness for five of ten sampled residents. On 11/16/24, several residents reported being served undercooked chicken, with red juices contaminating other foods on their plates. Residents R2, R5, R7, R8, and R10, all cognitively intact, expressed concerns about the undercooked chicken and the lack of alternative meal options, which left them hungry. Despite these complaints, there was no formal investigation to determine the cause of the undercooked chicken, the number of residents affected, or the necessary steps to prevent potential foodborne illness. The Dietary Manager (DM) was not present on the day the undercooked chicken was served and only learned of the issue afterward. The DM checked the leftover chicken and found some pieces slightly pink but not bloody, and the cook denied any undercooking. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were informed of the issue, but the NHA concluded that only one resident had a concern after informal discussions with a few residents. The incident was not processed through the grievance system, and no interviews were conducted with the CNAs who served the meal, indicating a lack of thorough investigation and response to the residents' complaints.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to properly identify and address grievances from residents, as evidenced by the experiences of two residents, R2 and R3. R2, who was cognitively intact, reported an incident where she and other residents were served undercooked chicken, which was inedible, leaving her hungry. Despite reporting this as a formal complaint to the Dietary Manager (DM), no grievance form was initiated, and no follow-up was conducted. The DM acknowledged the complaint but did not take further action to investigate or document it as a grievance. The Social Services Grievance Official was unaware of the incident, and the Nursing Home Administrator (NHA) handled the issue informally without following the grievance process. R3's family member expressed multiple concerns regarding the handling of R3's laundry and meal services, including missing and damaged clothing, and a meal tray left in R3's room with gnats. Although these grievances were documented, the family member did not receive written responses or resolutions, and was often dissatisfied with the verbal outcomes provided. The facility's policy required written decisions on grievances, but this was not adhered to, as confirmed by the Social Services staff and the NHA, who stated that results were typically communicated verbally. The facility's failure to follow its grievance policy resulted in a lack of formal documentation and resolution of resident complaints. The designated Grievance Official was not informed of all grievances, and the process for issuing written decisions was not followed, leading to unresolved issues and dissatisfaction among residents and their families. This deficiency highlights a breakdown in the facility's grievance handling process, impacting the residents' right to voice concerns and receive appropriate responses.
Failure to Serve Food at Appropriate Temperature
Penalty
Summary
The facility failed to serve food at the appropriate temperature, affecting two residents who reported that their meals were not hot enough. Both residents were cognitively intact, as indicated by their BIMS scores of 15 out of 15. During an observation, one resident stated that the BBQ rib patty was not very hot, while another resident confirmed the same but noted that the taste was acceptable. The Dietary Manager (DM) confirmed that the BBQ rib patty was lukewarm and that the plate was cold, which contributed to the food not being served at the proper temperature. The DM used an infrared thermometer to check the temperature of the BBQ rib patty, which read 125 degrees, below the required serving temperature of 135 degrees. The steam table holding temperature was recorded at 186 degrees, indicating a discrepancy between the holding and serving temperatures. The Maintenance Director (MD) later discovered a malfunction in the steam table, with one well reading 120 degrees due to a broken switch on the circuit board. This issue was not known to the facility until the deficiency was identified.
Failure to Monitor Narcotic Medication Delivery
Penalty
Summary
The facility failed to monitor the delivery of narcotic medication for a resident, leading to a deficiency in pain management. The resident, who was cognitively intact and had a history of stroke, breast cancer, osteoarthritis, anxiety, and asthma, was admitted with orders for Oxycodone and Acetaminophen (APAP) for pain management. The resident reported that she usually took Oxycodone once a day and did not need APAP. However, from 03/04/24 to 03/08/24, the facility did not have Oxycodone available for the resident, and she had to rely on APAP, which was not as effective for her pain relief. The issue arose because the facility did not ensure a new prescription for Oxycodone was obtained in a timely manner. The Licensed Practical Nurse (LPN) and the Director of Nurses (DON) both assumed that the pharmacy would contact the physician for a new prescription, as was sometimes the practice. However, there was no documentation of such communication, and the pharmacy did not receive a prescription from the physician until 03/08/24. The resident experienced pain during this period, and although the facility provided APAP and non-pharmacological interventions, the resident reported that the pain relief was not as effective as with Oxycodone. The deficiency was further compounded by a lack of documentation and communication between the facility, the pharmacy, and the physician. The DON and LPN believed that the pharmacy would handle the prescription renewal, but there was no follow-up to ensure the prescription was sent and filled. The physician also assumed the prescription was filled after sending it on 03/05/24, but the pharmacy did not receive it until 03/08/24. This lack of coordination and documentation led to the resident being without her prescribed Oxycodone for several days, affecting her pain management.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures for two residents on one of its units. Resident 1, who was alert and oriented, reported that her food was often cold and beverages were not cold enough. She had previously complained about the issue and was advised to ask staff to reheat her food, which she found unpalatable when reheated. Similarly, Resident 4 also reported that her food was sometimes cold and did not taste good when reheated. The Dietary Manager stated that since the purchase of two food carts with heating elements, there had been only a few complaints about cold food. However, the facility's grievance log documented Resident 1's ongoing concerns about cold food. The review of the facility's food temperature logs revealed a lack of documentation for milk and coffee temperatures before leaving the kitchen. During an observation, it was noted that food items were not adequately covered, and the temperatures of the test tray items were below acceptable levels, with the cheeseburger, French fries, pineapples, and milk being lukewarm and not palatable. The facility's policy required hot foods to be held at 135 degrees Fahrenheit or greater and cold foods at or below 41 degrees Fahrenheit. However, the test tray temperatures were significantly lower than these standards. The Dietary Manager acknowledged that the food cart might not have been plugged in early enough, contributing to the cooler food temperatures. The Director of Nurses confirmed that the temperatures were not at acceptable levels, indicating a failure to adhere to the facility's food temperature policies.
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.
