Complete Care At Jefferson Meadows Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Baraboo, Wisconsin.
- Location
- 1414 Jefferson St., Baraboo, Wisconsin 53913
- CMS Provider Number
- 525317
- Inspections on file
- 16
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Complete Care At Jefferson Meadows Llc during CMS and state inspections, most recent first.
Three residents did not receive adequate nutrition and hydration due to the facility's failure to monitor and document fluid and food intake, update care plans and assessments after significant changes in condition, and communicate with the physician or registered dietitian as required. One resident suffered actual harm, including hospitalization for severe dehydration, while two others experienced significant weight loss and inconsistent monitoring of their nutritional needs.
Dietary staff were observed handling food with bare hands and without performing hand hygiene, as well as entering food service areas without required hair restraints. These actions violated facility policy and were confirmed as unacceptable by dietary staff and management.
Surveyors observed that six expired stock antibiotic ointments, including bacitracin zinc and triple antibiotic ointments, were present in the medication room. The DON confirmed these medications were expired and should not have been available, indicating a failure to follow facility policy for medication storage and removal of outdated drugs.
Surveyors identified that multiple residents did not have documentation of MD or NP visits in their medical records, either in the EHR or paper charts. Staff interviews revealed inconsistent access to and retrieval of visit notes, with some staff not regularly checking the EHR and others lacking access altogether. Facility policies requiring tracking and documentation of physician visits were not consistently followed, resulting in incomplete and inaccessible medical records.
The facility did not follow its antibiotic stewardship protocols by failing to verify infection criteria and monitor symptoms and treatment effectiveness for several residents started on antibiotics for UTIs and pneumonia. Required documentation of infection assessment and ongoing monitoring was missing, despite staff stating that such protocols were in place.
The facility did not complete or maintain required PASRR Level I and Level II screenings for two residents with mental health diagnoses. For one resident, no PASRR Level I was found, and for another, a PASRR Level II was missing despite a Level I with a 30-day exemption. The social worker and DON confirmed the absence of necessary documentation and acknowledged that PASRRs should be completed and kept in the medical record.
A resident with severe cognitive impairment was repeatedly observed without meaningful activities, spending most days napping or roaming the halls. Despite a care plan outlining the need for therapeutic recreation and staff support, the facility did not consistently provide individualized activities or adequate documentation of participation, resulting in unmet physical, mental, and psychosocial needs.
A resident with severe cognitive impairment and malnutrition, who was receiving nutrition and medication via G-tube, did not have proper verification of tube placement prior to feeding. Nursing staff checked placement using only air, omitting the required aspiration of gastric contents as outlined in facility policy and the care plan. Both the nursing supervisor and DON confirmed that aspiration should have been performed.
A registered nurse was observed crushing and preparing to administer extended-release Levetiracetam tablets to a resident with epilepsy, contrary to facility policy and manufacturer instructions that prohibit crushing such medications. The nurse assumed all medications should be crushed due to the resident's swallowing difficulties, but the resident's chart did not specify this. The error was identified by surveyors before administration.
Two residents receiving hospice care did not have their current hospice plans of care available to facility staff, despite facility policy requiring coordination and documentation. Staff interviews revealed inconsistent processes for obtaining and reviewing hospice care plans, and documentation was limited to team listings and visit logs without substantive care information. The hospice plans of care were not found in the residents' charts or hospice binders, and staff had to request them from external sources.
A resident with moderate cognitive impairment and a history of trauma was repeatedly subjected to verbal abuse, including yelling and profanity, by her activated POA. Despite multiple incidents witnessed and reported by staff, the facility did not implement or document specific interventions in the care plan or Kardex to prevent further abuse or ensure the resident's safety during visits. Staff awareness of the situation and required actions was inconsistent, and the facility failed to ensure effective measures were in place to protect the resident from ongoing verbal abuse.
Staff failed to immediately intervene when a resident was subjected to alleged verbal abuse by her POA, despite overhearing loud yelling and profanity. The CNA and RN reported the incident to the DON but did not enter the room or ensure the resident's immediate safety. The resident, who had cognitive impairment and was identified as vulnerable to abuse, was found crying after the incident. Staff interviews indicated uncertainty about specific interventions and a lack of immediate protective action during the event.
A resident with moderate cognitive impairment, a history of trauma, and recent bereavement did not have a comprehensive, person-centered care plan that incorporated behavioral health recommendations for grief and trauma support. Despite receiving behavioral health services and having specific interventions recommended by psychology, these were not included in the care plan, and staff were not fully informed of the resident's trauma history.
The facility did not monitor or document water heater and hot water storage tank temperatures as required by its infection prevention and control program, leaving it unable to demonstrate compliance with national standards for minimizing Legionella risk. Interviews with maintenance staff and the administrator confirmed the absence of temperature logs, despite policy requirements and a work order system intended for regular checks. This deficiency had the potential to impact all residents in the facility.
A facility failed to assess the risks of using side rails with air mattresses, leading to a resident's entrapment and subsequent death. The resident, with severe dementia and reduced mobility, was not properly assessed for entrapment risks when their mattress was changed to a Panacea Convertible Mattress with powered alternating-pressure therapy. The facility did not document alternatives to side rails or provide updated risk information to the resident's Health Care Power of Attorney. This oversight resulted in immediate jeopardy findings.
Failure to Ensure Adequate Nutrition and Hydration for Multiple Residents
Penalty
Summary
The facility failed to ensure adequate nutrition and hydration for three residents, resulting in one resident experiencing actual harm and two others being placed at risk for more than minimal harm. For one resident with severe dementia, the facility did not total or assess daily fluid intake, failed to accurately assess and document ongoing signs and symptoms of dehydration, and did not update care plans or nutritional assessments after a significant change in condition that led to hospitalization for severe hypernatremia and dehydration. Despite clear evidence of declining intake and physical changes, there was no documentation of interventions attempted or communication with the registered dietitian prior to the hospitalization. Staff interviews confirmed that the resident required assistance and encouragement to eat and drink, but this was not consistently documented or reflected in updated care plans. Another resident experienced significant weight loss, but the facility did not appropriately notify the physician or nurse practitioner, started a nutritional supplement without a physician's order, and failed to monitor the amount of supplement consumed. The dietary assessment for this resident had not been updated in over a year, and there was no comprehensive documentation of calorie, protein, or hydration needs. Staff interviews revealed confusion about the process for supplement administration and tracking, and the resident reported dissatisfaction with the food and lack of snacks. A third resident's fluid intake was not monitored, and the physician was not notified of a severe weight loss of 10% over two weeks. The resident's favorite beverage was not added to the care plan as required by facility policy, and a complete nutrition assessment by the registered dietitian was not conducted. Documentation of fluid intake was inconsistent, and the resident was not consistently offered snacks. Facility policies required systematic assessment, monitoring, and documentation of hydration and nutrition, but these were not followed for the residents reviewed.
Failure to Maintain Safe and Sanitary Food Handling Practices
Penalty
Summary
Surveyors observed that dietary staff failed to follow safe and sanitary food handling practices during food preparation and service. Specifically, staff were seen directly touching sausage and the inside lip of fruit cups with their bare hands, without wearing gloves or performing hand hygiene. Additionally, staff entered the kitchen and food service area without wearing required hair restraints while food service was ongoing. These actions were in direct violation of the facility's Food Safety Requirements policy, which mandates the use of gloves, tongs, or other barriers when handling food and requires hair restraints in food preparation and service areas. Interviews with dietary staff and the dietary manager confirmed that these practices were not acceptable and were contrary to established policy.
Expired Antibiotic Ointments Found in Medication Room
Penalty
Summary
Surveyors found that the facility failed to ensure drugs and biologicals were stored and labeled according to accepted professional standards in the medication room. During an observation with the Director of Nursing (DON), six expired stock antibiotic ointments were discovered, including three bacitracin zinc ointments and three triple antibiotic ointments (bacitracin zinc/neomycin sulfate/polymyxin B sulfate), all past their expiration dates. The expired medications were present in the medication storage room, contrary to facility policy and professional guidelines. The facility's policy requires that all medications be stored according to manufacturer recommendations and that discontinued, outdated, or deteriorated medications be routinely inspected and destroyed as appropriate. However, the presence of these expired ointments indicated that the required inspections and removals had not been adequately performed. The DON confirmed during interview that the expired creams should not have been in circulation and verified their expired status.
Failure to Maintain and Document MD/NP Visit Notes in Resident Medical Records
Penalty
Summary
Surveyors found that the facility failed to maintain complete, accurate, and readily accessible medical records for all residents reviewed. Specifically, for 13 residents, there was no documentation of routine or acute visits by medical doctors (MD) or nurse practitioners (NP) in either the electronic health record (EHR) or paper charts. This lack of documentation was discovered during a review of records and interviews with staff, who confirmed that visit notes were not regularly obtained or filed in the residents' records. Facility policies require licensed nurses to track physician visit due dates, remind physicians to document visits, and for the Director of Nursing or designee to conduct monthly audits for timeliness. Additionally, all assessments, observations, and services provided are to be documented in accordance with state law and facility policy. Despite these policies, staff interviews revealed inconsistent practices regarding access to and retrieval of MD/NP visit notes. Some staff had access to the EHR but did not check it regularly, while others lacked access entirely and relied on supervisors for information. Further interviews with the Nursing Supervisor, RNs, LPNs, the Nursing Home Administrator, and Medical Records staff indicated a lack of clarity and consistency in responsibility for obtaining and tracking MD/NP visit documentation. The Medical Records staff acknowledged that a comprehensive review had not been conducted recently, and that obtaining visit notes had not been consistently performed. As a result, the facility did not have the required MD/NP visit notes readily accessible in the health records for the residents reviewed.
Failure to Monitor and Document Antibiotic Use per Stewardship Protocols
Penalty
Summary
The facility failed to follow its own antibiotic stewardship program and standards of practice for monitoring antibiotic use, as evidenced by the lack of verification that infection criteria were met and insufficient monitoring of symptoms and treatment effectiveness for several residents started on antibiotics. The policy required nursing staff to assess residents suspected of infection, verify infection criteria (such as McGeer's Criteria), and document both the initiation and ongoing monitoring of antibiotic therapy, including an antibiotic timeout within 48-72 hours. However, for multiple residents, there was no documentation that these steps were followed. One resident with a history of cystitis and chronic kidney disease was started on antibiotics for urinary symptoms, but the facility did not document whether infection criteria were met or monitor symptoms and effectiveness of treatment during and after the antibiotic course. Another resident with encephalopathy and failure to thrive was prescribed antibiotics for a UTI, but there was no documentation of infection criteria assessment or monitoring of symptoms and treatment response. Similarly, a resident with multiple sclerosis and overactive bladder was started on antibiotics for a UTI based on staff observations and lab results, but again, there was no documentation of infection criteria review or monitoring of symptoms before or after starting antibiotics. Additionally, a resident with chronic obstructive pulmonary disease and paroxysmal atrial fibrillation was treated for pneumonia after a chest x-ray, but the facility did not document whether infection criteria were met or monitor symptoms and effectiveness of antibiotic treatment. Interviews with facility staff confirmed that while McGeer's Criteria were referenced, there was no documentation of their use, and no evidence of required monitoring or assessment was found in the records. The facility's failure to document these critical steps led to the deficiency.
Failure to Complete and Document Required PASRR Screenings
Penalty
Summary
The facility failed to follow the required Preadmission Screening and Resident Review (PASRR) process for two residents. For one resident with diagnoses including dementia, depression, and mood disorder, there was no documentation of a PASRR Level I screening being completed prior to admission, as required by facility policy and Medicaid rules. The social worker confirmed that no PASRR documentation could be found for this resident, indicating that the initial screening step was missed. For another resident with diagnoses such as delusional disorders, restlessness, and agitation, a PASRR Level I was submitted with a 30-day exemption, but there was no documentation of a required PASRR Level II evaluation. The social worker was unable to provide evidence that the Level II evaluation had been completed, and the Director of Nursing confirmed that PASRRs should be completed timely and maintained in the resident's medical record. These lapses demonstrate that the facility did not ensure the appropriate PASRR steps were followed and documented for residents with mental disorders or intellectual disabilities.
Failure to Provide Individualized Activity Program for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of a resident with severe cognitive impairment. Observations over multiple days showed the resident sitting in a hallway, often staring at a wall, with no meaningful activities offered. Documentation from January to May indicated the resident primarily napped or roamed the halls, with minimal participation in activities such as family visits, animal therapy, or group events. The resident's care plan specified the need for therapeutic recreation, including weekly one-on-one visits, group activities, and the provision of comfort items like baby dolls, but these interventions were not consistently implemented. Interviews with staff revealed that the resident was unable to structure her own leisure time and required staff support to attend activities. Staff acknowledged that activity documentation lacked details on duration, participation level, and enjoyment, and that alternative activities were not offered if the resident was napping during scheduled events. The activity director confirmed that the resident enjoyed sensory activities, music, and outdoor time, but required assistance to access these opportunities. Despite these identified needs and preferences, the facility did not ensure an ongoing, individualized activity program for the resident.
Failure to Properly Verify G-Tube Placement Prior to Feeding
Penalty
Summary
A deficiency occurred when a resident receiving nutrition and medication via a G-tube did not receive appropriate treatment and services as required by facility policy and the resident's care plan. The facility's policy and the resident's care plan both required that tube placement be verified before each feeding and medication administration by both auscultation and aspiration of gastric contents. However, during observation, a registered nurse checked the G-tube placement using only air and did not aspirate gastric contents prior to administering the tube feeding. The nurse acknowledged in an interview that she typically does not aspirate gastric contents, despite knowing it is required. Further interviews with the nursing supervisor and the director of nursing confirmed that their expectation is for staff to both listen for air flow and aspirate gastric contents when checking G-tube placement. The resident involved had significant cognitive impairment, severe protein-calorie malnutrition, and was at risk for complications related to tube feeding. The failure to follow established protocols for verifying tube placement and aspirating gastric contents prior to feeding constituted a deficiency in care for this resident.
Crushing of Extended-Release Medication by RN
Penalty
Summary
A deficiency occurred when a registered nurse (RN) prepared to administer medications to a resident diagnosed with generalized idiopathic epilepsy and epileptic syndromes. The RN was observed crushing seven medications, including two tablets of Levetiracetam ER (an extended-release anticonvulsant), despite facility policy and manufacturer instructions that specifically prohibit crushing extended-release medications. The facility's policy requires medications to be administered as ordered and in accordance with manufacturer specifications, including not crushing medications labeled as 'do not crush.' The RN admitted to crushing the Levetiracetam ER tablets based on an assumption that the resident, who had a history of stroke and difficulty swallowing, required all medications to be crushed. The resident's chart did not specify administration instructions for these medications. The error was identified by surveyors before the medications were administered, and the RN acknowledged that she would not have caught the error without their intervention.
Failure to Ensure Hospice Plan of Care Availability and Coordination
Penalty
Summary
The facility failed to ensure proper collaboration and communication with hospice providers for two residents receiving hospice care. For both residents, the current hospice plan of care was not available to facility staff, despite the facility's policy requiring coordination and documentation of hospice interventions. Interviews with nursing staff, including the RN, Nursing Supervisor, MDS/Infection Preventionist, and DON, revealed inconsistent understanding and execution of processes for obtaining, reviewing, and integrating the hospice plan of care into the facility's records. Staff were either unaware of the location of the hospice plan of care or stated that it was not provided or reviewed, and documentation in the hospice communication binder was limited to team listings and visit logs without substantive care information. One resident had diagnoses including corticobasal degeneration, Alzheimer's disease, and was receiving palliative care. The facility's care plan referenced hospice involvement and directed staff to see the hospice plan of care, but this document was not found in the resident's chart or the hospice binder. Staff interviews confirmed that the hospice plan of care was not reviewed or integrated into the facility's care planning process, and the designated hospice liaison did not review the hospice plan of care. The second resident, with a history of hemorrhagic stroke, quadriplegia, and vascular dementia, was also receiving hospice care. The resident's care plan included interventions to coordinate with hospice and notify them of changes, but the hospice plan of care was not present in the paper chart, electronic medical record, or hospice binder. Facility staff had to request the hospice plan of care from an external electronic health record, indicating a lack of immediate access and integration. The DON confirmed the expectation that the facility should review and align the hospice plan of care with the facility's plan, but this was not occurring.
Failure to Protect Resident from Repeated Verbal Abuse by POA
Penalty
Summary
A resident with moderate cognitive impairment and a history of childhood abuse was subjected to repeated verbal abuse by her activated Power of Attorney (POA) while at the facility. The POA was reported to have yelled, used profanity, and displayed aggressive behavior toward the resident on multiple occasions, including incidents where staff overheard loud, profane language and observed the resident crying. Despite these events, the facility did not implement or document specific interventions to prevent further verbal abuse or to ensure the resident's safety during visits from the POA. The resident's care plan and Kardex did not include any interventions or increased monitoring related to the POA, even though the facility's policies defined verbal abuse and allowed for visitation restrictions in cases of emotionally harmful behavior. Staff interviews revealed a lack of awareness regarding any interventions or special precautions for the resident when the POA was present. While some staff were aware of a memo at the nurse's station instructing them to report any yelling by the POA, this information was not consistently communicated to all staff, including new or agency staff, and was not reflected in the resident's care documentation. Multiple staff members, including CNAs, nurses, and support staff, acknowledged hearing or being aware of the POA's verbally abusive behavior toward the resident. However, there was inconsistency in staff responses, with some not intervening or being unclear about the appropriate actions to take. The facility leadership chose not to document interventions in the care plan or Kardex, citing concerns about the POA's access to these documents. As a result, the facility failed to ensure that effective measures were in place to protect the resident from ongoing verbal abuse by the POA.
Failure to Immediately Intervene During Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to immediately intervene when staff heard alleged verbal abuse directed at a resident by her power of attorney (POA). Staff, including a CNA and an RN, overheard loud yelling and profanity coming from the resident's room, with the POA using explicit language and raising her voice. The CNA reported the incident to the nurse, who then notified the Director of Nursing (DON), but neither staff member entered the room or directly intervened to ensure the resident's immediate safety at the time the abuse was occurring. The resident involved had a history of cognitive impairment, including dementia and mood disorders, and was identified as vulnerable to abuse in her care plan. When the DON and Nursing Home Administrator (NHA) entered the room, the POA's behavior de-escalated, but the resident was observed crying. The resident stated she felt safe with her POA and wanted visits to continue, but staff and social services confirmed that this was not the first time the POA had yelled at the resident. Despite the facility's abuse prevention policy requiring immediate protection and intervention for residents at risk, staff did not act promptly to protect the resident during the incident. Staff interviews revealed that while there had been recent education on abuse reporting, the CNA and RN did not physically check on the resident or intervene during the altercation, instead relying on reporting the incident up the chain of command. The care plan and other documentation did not include specific interventions for staff to follow in such situations, and staff were uncertain about what measures were in place to keep the resident safe during and after such incidents.
Failure to Develop Person-Centered Care Plan for Behavioral Health Needs
Penalty
Summary
A deficiency was identified when the facility failed to comprehensively assess and develop a person-centered care plan for a resident experiencing ongoing grief and sadness following the recent loss of her son, as well as past trauma. The resident, who has diagnoses including unspecified dementia, major depressive disorder, and other behavioral and emotional disorders, was found to be moderately cognitively impaired and had an activated power of attorney. Despite receiving behavioral health services and having a documented history of significant trauma and recent bereavement, the facility did not incorporate recommended interventions from behavioral health professionals into the resident's care plan. The resident's trauma screening assessment revealed a history of physical and sexual abuse, life-threatening illness, severe human suffering, and the sudden, unexpected death of someone close. A psychology appointment documented maladaptive behavioral symptoms, emotional distress, and specific recommendations for care, such as increasing positive emotions, integrating faith-based support, encouraging socialization, and providing validation during episodes of grief. However, these recommendations were not reflected in the resident's comprehensive care plan or Kardex, which only included general statements about encouraging activity participation and observational behavior monitoring. Interviews with facility staff, including the Nursing Home Administrator and Director of Social Services, confirmed that the recommended interventions from behavioral health were not care planned and that staff were not fully aware of the specifics of the resident's trauma. Observations showed the resident was tearful and withdrawn, and while she reported some support from nursing staff, the lack of a comprehensive, individualized care plan addressing her grief and trauma constituted a failure to provide necessary behavioral health care and services.
Failure to Monitor Water Heater Temperatures per Infection Control Policy
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program as required by policy and national standards. Specifically, the facility did not monitor or document the temperature of the water heater (WH) or hot water storage tank (HWT) as outlined in their Water Management Program. The program required that water heater and storage tank outlet temperatures be maintained at or above 140 degrees Fahrenheit to prevent the growth of Legionella and other waterborne pathogens. Interviews with the Maintenance Director and Maintenance Tech revealed that while there was a work order in the maintenance management system to check water temperatures monthly, no records or logs of temperature readings could be found. The new Maintenance Director confirmed that there was no documented monitoring of the WH or HWT temperatures. Further, the Nursing Home Administrator acknowledged that a previous maintenance director had implemented a robust plan for temperature testing, but no documentation could be produced to verify ongoing monitoring or compliance with the facility's water management protocols. The lack of documented temperature monitoring meant the facility could not demonstrate that control measures were being followed to minimize the risk of Legionella and other pathogens, as required by their infection prevention and control policy and national guidelines. This deficiency had the potential to affect all 48 residents residing in the facility.
Failure to Assess Risks of Side Rails with Air Mattresses
Penalty
Summary
The facility failed to ensure that alternatives were tried before installing and utilizing side rails for residents, particularly those using an air mattress. This oversight was evident in the case of a resident who was admitted with severe dementia, reduced mobility, osteoporosis, and cerebrovascular disease. The facility implemented the use of side rails without assessing the risks associated with combining them with an air mattress, which increases the risk of entrapment. The resident became entrapped in the side rail, resulting in multiple fractures and subsequently passed away the following day. The facility did not conduct a proper assessment for entrapment risks when changing the resident's mattress to a Panacea Convertible Mattress with powered alternating-pressure therapy. Additionally, the facility failed to provide new risk and benefit information to the resident's Health Care Power of Attorney when the mattress was changed. The facility's Bed System Measurement Device, which is not recommended for use with alternating air mattresses, was used without proper documentation, and quarterly bed/side rail measurement tests were not completed as per facility policy. The deficiency was further highlighted by the facility's failure to document any alternatives attempted before utilizing bed rails for other residents. The facility did not provide evidence of alternative interventions being tried prior to the installation of bed rails for other residents using similar air mattresses. This lack of assessment and documentation contributed to the finding of immediate jeopardy, as the facility did not recognize the increased risk of entrapment posed by the combination of side rails and air mattresses.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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