Complete Care At Maple Grove Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Wisconsin.
- Location
- 3401 Maple Grove Dr., Madison, Wisconsin 53719
- CMS Provider Number
- 525276
- Inspections on file
- 27
- Latest survey
- July 29, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Complete Care At Maple Grove Llc during CMS and state inspections, most recent first.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not maintained safely and supervision was lacking, but does not specify further details.
Three residents at the facility did not receive fall interventions as outlined in their care plans, nor adequate supervision to prevent accidents. One resident with a history of frequent falls, including a head injury, was not provided increased supervision despite repeated incidents in similar settings. Another resident was observed ambulating without her walker and lacked the required reminder signage. A third resident with wandering and behavioral issues was not given additional supervision to prevent entry into other residents' rooms, increasing the risk of altercations.
Staff did not consistently follow professional standards for food service safety, as a dietary aide failed to allow the thermometer to dry after sanitizing before checking food temperatures and did not check all required food items, including ground and pureed foods. The dietary manager confirmed that all food temperatures should be taken and that the thermometer should be dry before use, but these practices were not followed.
Several residents reported that a cognitively impaired resident repeatedly entered their rooms uninvited, sometimes sitting on their beds or in their wheelchairs, and in one instance, causing pain by sitting on a recent surgical site. Staff were aware of the ongoing intrusions and attempted redirection and other interventions, but these were not effective in preventing the behavior. The facility did not implement measures to stop the unwanted entries, resulting in a failure to protect residents' dignity and privacy.
Surveyors found that multiple medications, including PRN and as-needed drugs, were expired or lacked proper labeling such as open dates on a medication cart. An LPN confirmed that medications should be checked for expiration before administration and that expired drugs should be discarded. The DON reported that the pharmacist is responsible for auditing medication carts and rooms, but checks may only occur monthly and require advance scheduling. These findings indicate that the facility did not consistently follow its own policy for medication storage and labeling.
A resident with multiple medical conditions, including arthritis and macular degeneration, was observed with medications left at the bedside for self-administration without a completed assessment or physician order. Staff left medications based on the resident's preference, but documentation and interviews revealed the resident could not identify her medications and had recently needed assistance. The required assessment process was not followed prior to allowing self-administration.
A resident raised concerns about staff using personal cell phones during work hours, but the facility did not document or investigate the grievance as required by policy. Surveyors observed multiple LPNs using cell phones for personal matters, and the resident reported no follow-up on her complaint. The grievance was not entered into the log, and the required investigation and resolution steps were not completed.
A resident with moderate cognitive impairment and mobility needs was repeatedly observed seated in a Broda chair with the brakes engaged, preventing self-movement. The brakes were positioned out of the resident's reach, and staff interviews confirmed that this restricted the resident's freedom of movement, meeting the facility's definition of a physical restraint. The care plan did not indicate a medical need for this restraint.
Three residents did not have their individual needs and preferences addressed in their care plans, including one resident whose care plan for interpreter services was not followed, and two residents whose religious practices as Muslims were not included in their care plans. Staff were unaware of the residents' language or religious requirements, and facility policy requiring person-centered, culturally competent care planning was not met.
A resident with moderate cognitive impairment and multiple medical conditions expressed a desire to move to assisted living, but the care plan continued to reflect a long-term stay in the facility. Although the social worker was aware of the resident's goal and began working on placement, the care plan was not updated to match the resident's current wishes, as confirmed by both the SW and DON.
Two residents who are practicing Muslims did not have their religious and cultural needs accommodated, as their care plans failed to reflect their preferences for prayer and cleanliness. Both residents reported being unable to practice their faith as required, and staff interviews revealed a lack of awareness or incorrect information about their religious needs. Facility policies requiring person-centered care and respect for resident choices were not followed.
Two residents who were dependent on staff for ADL support did not receive timely assistance with personal hygiene, grooming, and toileting as required by their care plans. One resident was repeatedly observed with unkempt hair and long whiskers, while another was left in urine-soaked clothing for extended periods. Staff interviews and documentation revealed inconsistent care and a lack of adherence to facility policies, resulting in compromised dignity and unmet care needs.
A resident with a stage 4 pressure injury did not receive care as ordered by the physician, including required repositioning and time limits in a wheelchair. Staff were unaware of the specific repositioning schedule, and the care plan and care card did not reflect the individualized orders. The resident was observed remaining in her wheelchair beyond the allowed time without repositioning, and the facility could not provide a pressure injury care policy when requested.
A resident with chronic pain and multiple medical conditions experienced ongoing pain during transfers with an EZ stand lift, despite repeatedly expressing discomfort and requesting alternative methods. Facility staff and leadership were aware of the resident's pain, but did not reassess her pain management plan, update her care plan, or implement new transfer approaches, resulting in continued daily pain.
A resident with a history of falls and cognitive impairment experienced multiple falls from a lift chair, including one resulting in a femur fracture, after the facility failed to assess the resident's ability to safely use the chair and did not provide adequate supervision or staff education on fall prevention.
A resident with a physician-ordered Level 7: Easy to Chew diet was regularly provided with snacks such as cheese crackers, Cheetos, and potato chips by staff and family, despite these items not being compliant with her prescribed diet. Staff, including a speech therapist, allowed these exceptions for quality of life reasons but did not document them or update the care plan. The registered dietician and DON confirmed that these exceptions were not communicated or recorded in the resident's medical record.
A resident's medical record contained conflicting care plan entries regarding their ability to self-administer medication, with some documentation allowing self-administration and other entries prohibiting it and requiring observation. Staff interviews revealed confusion about the resident's self-medication status, and no physician order authorizing self-administration was found in the EMR. The DON acknowledged the conflicting information in the care plan.
The facility failed to properly install and test bed rails for four residents, leading to potential safety risks. Bed rails were installed without conducting necessary tests to ensure proper installation and reduce entrapment risks. The Maintenance Supervisor admitted that a new employee, untrained in using the measurement device, was installing bed rails, and several installations had not been tested. The Nursing Home Administrator confirmed that testing should occur upon installation, but the facility lacked documentation of actual installation dates.
A resident, who required two-person assistance for bed mobility, fell out of bed when a CNA attempted to assist her alone, contrary to her care plan. The resident became wedged between the bed and the wall, highlighting the facility's failure to ensure staff were trained and aware of care plans. The Nursing Home Administrator was unaware of the frequent single-staff assistance, and several staff members had not received necessary education or competency testing.
A resident with quadriplegia was burned by hot coffee served at 185°F in bed, as the facility lacked safety protocols for hot liquids. The resident attempted to switch the coffee cup from his left to his weaker right hand, resulting in a spill and burns. The facility did not assess the safety of serving hot liquids to residents, nor did it monitor beverage temperatures, leading to this incident.
A resident receiving psychotropic and antipsychotic medications was not adequately monitored for behavior and side effects, leading to unnecessary medication use. The facility failed to document quantitative behavior tracking, using inappropriate charting methods. Staff interviews indicated the resident's behaviors were not harmful, contradicting the need for antipsychotic medication.
A resident with dysphagia and a history of aspiration events experienced two choking incidents due to inadequate supervision and failure to adhere to dietary restrictions. The resident was served inappropriate food items, leading to hospitalization. Staff interviews revealed a lack of clarity and responsibility in verifying meal tickets and ensuring correct diets, contributing to the deficiency.
The facility did not conduct annual performance reviews for three CNAs, as required by its policy. The last evaluations for these CNAs were conducted in 2022, despite their long-term employment. The facility's leadership indicated that evaluations were conducted every three years, contrary to the policy's annual requirement.
A resident with Vitamin B Deficiency did not receive their prescribed Vitamin B Complex-C medication due to unavailability, and the facility failed to notify the physician as required by policy. Despite the ADON being informed of the medication error, the physician was not notified, leading to a deficiency identified by surveyors.
A resident with cognitive intactness and multiple medical conditions reported a grievance about a CNA leaving her unable to eat her meal. The charge nurse was informed and reported the incident to the DON, but the grievance was not followed up on or formally documented, violating the facility's grievance policy.
A facility failed to report an alleged verbal abuse incident involving a resident to the State Agency. The resident's daughter reported that a CNA yelled at her mother, but the NHA closed the grievance due to lack of additional information from the daughter. The NHA acknowledged that the incident should have been reported as verbal abuse.
The facility failed to thoroughly investigate abuse allegations involving two residents. One resident was neglected during the night shift, and the investigation lacked interviews with day shift staff and other residents. Another resident's verbal abuse allegation was inadequately investigated, with no follow-up for non-verbal residents. The facility's policy for timely and thorough investigations was not followed.
A resident at risk for pressure injuries developed an infected pressure injury on her left foot bunion due to the facility's failure to implement timely interventions and assess contributing factors such as footwear. Despite being cognitively intact and having a care plan noting skin integrity risks, the facility did not conduct daily diabetic foot checks or address the cause of the initial redness, leading to the injury's progression and infection.
A facility failed to provide daily diabetic foot care for a resident with Type 2 Diabetes Mellitus, as required by their policy. The resident lacked a physician order for daily foot checks, resulting in the task not appearing on the TAR. Nursing staff only performed checks if listed on the TAR, and the DON confirmed checks were done weekly instead of daily, contrary to policy.
A resident with neurocognitive disorder and muscle weakness, who required 1:1 supervision due to wandering, was left unattended by a CNA, resulting in a fall. The resident's care plan lacked details on the required supervision, and the CNA acknowledged leaving the resident without ensuring a replacement. The RN and DON confirmed the need for continuous supervision, indicating a lapse in maintaining safety protocols.
A resident with Vitamin B Deficiency, Multiple Sclerosis, and Muscle Weakness did not receive their prescribed Vitamin B Complex-C Oral Capsule due to a failure in the facility's pharmaceutical services. Despite multiple attempts by staff to resolve the issue with the pharmacy, the medication was unavailable for several weeks, indicating a breakdown in communication and procedure.
The facility failed to establish an effective infection prevention and control program, affecting all 106 residents. Issues included incomplete daily infection control surveillance for staff, inaccurate infection control line lists, and improper calculation of infection control rates. Additionally, a CNA did not disinfect a resident's bedside table after placing a urinal on it, posing a risk of cross-contamination.
The facility failed to complete PASARR Level II screens for four residents with serious mental illnesses or intellectual disabilities who stayed longer than 30 days, despite initial exemptions. This oversight was due to a change in responsibility for completing assessments and a gap in social worker staffing.
The facility failed to provide an ongoing program of activities to meet the interests and well-being of residents, particularly on weekends and evenings. Seven residents voiced concerns about the lack of activities, especially missing church services on Sundays. The activity staff and Nursing Home Administrator acknowledged the issue but had not implemented changes to address the deficiency.
The facility failed to ensure proper storage and labeling of medications, with surveyors observing undated, open stock medications, improperly stored refrigerated medications, and co-mingled administration routes in medication carts. Additionally, some medications were found without labels or resident identification, and expired medications were not discarded as per manufacturer recommendations.
The facility failed to follow its antibiotic stewardship program, leading to inappropriate and prolonged antibiotic use for several residents. Staff did not always document or clarify the necessity and duration of antibiotics, resulting in unnecessary treatments.
A resident with dementia, requiring moderate assistance for eating, was observed with a plate of food that remained in front of her for 34 minutes before a CNA began feeding her. The food temperature was found to be 113 degrees Fahrenheit, and the facility staff replaced the food.
The facility failed to report alleged abuse and a missing narcotic pain patch to the appropriate authorities and did not suspend the staff member involved in the abuse allegation. The facility did not follow its own policies and procedures, compromising resident safety during investigations.
The facility failed to investigate a potential misappropriation of a narcotic pain patch for a resident with moderate cognitive impairment. Despite facility policy requiring immediate reporting and thorough investigation of such incidents, no investigation was initiated when the patch was found missing. Interviews confirmed the oversight, and the NHA acknowledged the concern.
The facility failed to complete a discharge MDS assessment for a resident who passed away, despite policy requirements and confirmation from the Director of Nursing that the assessment was missing. The resident had Alzheimer's disease and was receiving end-of-life care.
The facility failed to ensure accurate MDS coding for a resident's CPAP usage. The resident's MDS incorrectly marked 'NO' for CPAP usage despite physician orders indicating its use. The MDS Coordinator confirmed the error, and the Nursing Home Administrator acknowledged the expectation for accurate MDS assessments.
The facility failed to ensure weekly wound measurements for a resident with a left stump wound, despite the facility's policy and professional standards of practice. Only 3 out of 12 required measurements were documented, as confirmed by the wound nurse and DON.
A resident with Schizophrenia missed two doses of the antipsychotic medication Pimozide due to unavailability. The facility's protocol for handling medication unavailability was not fully adhered to, resulting in the missed doses. Staff interviews confirmed that the pharmacy was contacted, but the medication could not be delivered in time.
The facility failed to ensure proper documentation and administration of pneumococcal vaccinations for three residents. One resident had a signed consent form without evidence of administration, while two others had no documentation of consent, declination, or administration. The LPN/IP confirmed the lack of follow-up and documentation, indicating a failure to adhere to the facility's immunization policies.
The facility failed to ensure accurate and accessible nurse staffing postings, with multiple discrepancies between the Daily Staff Roster and the Daily Census/Staffing document. The postings were placed high on a wall with small text, making them difficult to read, and residents confirmed they could not read them.
The facility failed to provide pharmaceutical services to meet the needs of six residents, resulting in multiple instances where medications were not administered as ordered. Residents missed doses of critical medications due to unavailability and lack of proper documentation or follow-up.
The facility failed to provide a support person for a resident with multiple medical conditions, leading to the cancellation of her necessary medical appointments and causing significant distress. The facility's policy required family or friends to accompany residents, despite the resident's APOAHC living out of the country and being unable to provide support.
The facility failed to document, investigate, and resolve a grievance expressed by a resident's APOAHC regarding the treatment by a CNA. The grievance was not recorded in the facility's log, and no investigation details were found. The NHA confirmed that the grievance should have been documented and investigated thoroughly.
A facility failed to update a resident's care plan to include the need for a support person during external appointments. Despite being cognitively intact and having multiple diagnoses, the resident's care plan was not revised, leading to distress during an attempted appointment. The Nursing Home Administrator confirmed the oversight during a survey.
The facility failed to ensure proper incontinence care for three residents, who were found to be using double incontinence briefs or additional products without proper care planning. Despite the facility's policy against double briefing, staff and residents confirmed its use due to heavy wetting.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Failure to Implement Fall Interventions and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that fall interventions were implemented according to the care plan and that residents received adequate supervision to prevent accidents, as evidenced by the experiences of three residents reviewed for falls and supervision. One resident, who was identified as a fall risk and had a history of 23 falls since admission, experienced repeated falls in similar locations and times, including a fall resulting in a head injury that required sutures. Despite the facility conducting a root cause analysis and collecting data on these incidents, there was no evidence that the interdisciplinary team comprehensively reviewed the data or considered increasing supervision for this resident. The care plan included multiple interventions, such as moving the resident closer to the nurse's station and providing increased monitoring, but these were not consistently or effectively implemented, particularly in the dining room where several falls occurred without increased supervision. Another resident, who was care planned to walk with a walker and have a sign in her room as a reminder, was observed on two separate occasions walking without her walker. Additionally, the required sign was not present in her room, indicating a failure to implement care plan interventions designed to reduce fall risk. This lack of adherence to the care plan placed the resident at increased risk for falls. A third resident, known to have wandering behaviors and a history of acting out toward staff and other residents, was not provided with increased supervision to prevent entry into other residents' rooms. This lack of supervision created a risk for potential resident-to-resident altercations. The facility's fall prevention policy required individualized assessment and implementation of interventions based on risk, but the observed failures in supervision and care plan implementation for these residents demonstrate noncompliance with the policy and regulatory requirements.
Failure to Follow Food Service Safety Standards During Meal Preparation
Penalty
Summary
Staff failed to follow professional standards for food service safety during meal preparation and service. During observation, a dietary aide was seen taking food temperatures at the steam table but did not allow the thermometer to dry after cleaning it with an alcohol wipe before placing it into the next food item. This practice was repeated for all foods being checked. Additionally, the dietary aide did not take the temperature of all food items, specifically omitting ground and pureed foods on the steam table. When questioned, the dietary aide stated that only certain foods deemed important were being checked for temperature. The facility's policy requires that temperatures for each food product and milk be measured and recorded at all meals, and that thermometers used for this purpose must be clean, sanitized, and dry before use. The dietary manager confirmed that all food temperatures should be taken at every meal and that the thermometer should be dry before being used in another food item. These observations and staff interviews demonstrate that the facility did not consistently store, prepare, distribute, and serve food in accordance with professional standards for food service safety, potentially affecting all residents.
Failure to Prevent Resident Intrusions Violates Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity by not preventing a resident with dementia from repeatedly entering other residents' rooms uninvited. Multiple residents, including those who were cognitively intact and those with varying levels of cognitive impairment, reported that this resident would enter their rooms, sit on their beds or in their wheelchairs, and in one case, sat on a resident's recently operated knee, causing pain and distress. Staff and residents confirmed that these intrusions were ongoing and that the affected residents did not want this behavior to continue. Observations and interviews revealed that staff were aware of the wandering behavior and its impact on other residents. Staff described redirecting the resident as the primary intervention, but acknowledged that these efforts were not always effective. Some staff reported that the resident could become combative when redirected and that interventions such as walking with the resident, offering activities, or using visual cues like STOP signs had limited or no success. Documentation showed that the resident continued to wander into rooms, including at night, and that staff sometimes had to take turns sitting with her to prevent further incidents. Despite being aware of the problem and receiving grievances from residents, the facility did not implement effective interventions to prevent the resident from entering others' rooms uninvited. The affected residents expressed discomfort, frustration, and, in one case, physical pain as a result of these intrusions. The facility's actions and inactions led to a failure to honor residents' rights to dignity, privacy, and self-determination as required by policy and regulation.
Expired and Unlabeled Medications Found on Medication Cart
Penalty
Summary
Surveyors identified that the facility failed to ensure drugs and biologicals were properly labeled and stored according to professional standards on one of three medication carts reviewed. During observation, several medications were found to be expired, including PRN Hydralazine, Chest Congestion Relief, ondansetron, stimulant laxative, and calcium antacid cards. Additionally, a nasal spray lacked an open date, and eye drops had an open date but were not properly monitored for expiration. These findings were confirmed during interviews with an LPN, who acknowledged that medications should be checked for expiration before administration and that expired medications should be discarded. The Director of Nursing stated that the process for removing expired medications involves the consultant pharmacist auditing the carts and medication rooms, with expired items being sent back to the pharmacy. However, the DON indicated uncertainty about the frequency of these checks, believing it to be monthly and requiring advance scheduling. The facility's own policy requires routine inspection for discontinued, defective, or deteriorated medications, but the observed deficiencies indicate this process was not consistently followed.
Failure to Assess Appropriateness for Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was clinically appropriate to self-administer medications, as required by policy. A resident with diagnoses including polyosteoarthritis, type 2 diabetes mellitus, muscle weakness, and unspecified macular degeneration was observed with a cup of medications left on her bedside table for independent administration. There was no completed assessment or physician order in place at the time of the observation to support that the resident was safe to self-administer medications. The facility's policy requires an interdisciplinary assessment of the resident's physical and cognitive abilities, as well as a physician order, before allowing self-administration of medications. Record review showed that the resident had a BIMS score indicating cognitive intactness but required substantial to maximal assistance with activities of daily living and had limited range of motion in both upper extremities. The assessment tool used by the facility indicated that the resident could not name her medications, dosages, or reasons for use, and the assessment and order for self-administration were only completed after the surveyor's observation. Interviews with staff revealed that medications were left at the bedside based on the resident's preference to have them available before breakfast, but staff acknowledged that the resident did not meet all criteria for self-administration and that the required assessment process had not been followed prior to the incident. Further interviews with the resident and staff confirmed that the resident had recently needed help with medications and did not refuse to eat breakfast unless medications were present, contrary to staff assumptions. The staff responsible for completing the assessment had not directly discussed the process or the resident's preferences with her, and there was confusion among staff about the criteria required for self-administration. The deficiency was identified due to the lack of a completed assessment and physician order prior to allowing the resident to self-administer medications.
Failure to Investigate and Resolve Resident Grievance Regarding Staff Cell Phone Use
Penalty
Summary
The facility failed to document a thorough investigation and did not resolve a grievance as required by its own policy for one of four residents reviewed for grievances. A resident expressed concern during a Resident Council meeting about staff using personal cell phones while working. The concern was not entered into the facility's grievance log, and there was no documentation of an investigation or resolution. The Activities Director recalled the concern being brought to the previous Director of Nursing but was unsure if any follow-up occurred. The resident confirmed that no one had followed up with her regarding her concern, which remained unresolved at the time of the survey. Surveyors directly observed multiple staff members, including LPNs, using personal cell phones during work hours for non-work-related activities, such as opening a bank account, making a Facetime call, and discussing a resident. The Director of Nursing stated that there was no specific grievance documented regarding cell phones, although staff had reviewed cell phone expectations previously. The facility's policy requires the Grievance Official to oversee the grievance process, including receiving, tracking, investigating, and resolving grievances, as well as notifying the complainant of the outcome. These steps were not followed in this case.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
A deficiency occurred when a resident with dementia, seizure disorder, psychotic and mood disturbances, and moderate cognitive impairment was placed in a Broda chair with the brakes engaged while seated at the dining table. The brakes, located on the back lower wheels of the chair, were not accessible to the resident, preventing her from moving the chair independently. Multiple observations by the surveyor confirmed that the resident remained in this position for an extended period, attempting unsuccessfully to move the chair by grabbing the wheels, but was unable to do so due to the locked brakes. Interviews with facility staff revealed inconsistent understanding regarding the resident's ability to self-propel in the Broda chair and whether locking the brakes constituted a restraint. The facility's own policy defines a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. Despite this, the resident was repeatedly observed with the brakes engaged, restricting her movement, and staff acknowledged that this could be considered a restraint. The care plan indicated the resident required assistance with mobility and had a history of falls, but did not specify the use of restraints for medical treatment.
Failure to Develop and Implement Person-Centered Care Plans Addressing Communication and Religious Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed the individual needs, preferences, and cultural requirements of three residents. For one resident with Alzheimer's disease and polyosteoarthritis, the care plan included the use of interpreter services to communicate in her preferred language, Nepalese. However, interviews with staff revealed that they were unaware of the resident's language, had not used interpreter services, and instead relied on gestures or attempts to use translation apps, which were unsuccessful. The care plan's instructions for using interpreter services were not followed, resulting in ineffective communication with the resident. Two other residents, both practicing Muslims, did not have their religious preferences or needs reflected in their care plans. One resident expressed distress about being unable to pray as required by her faith due to cleanliness requirements and the lack of a clean space. The other resident reported being denied access to the chapel for prayer and felt that staff did not consider individual religious needs. Despite both residents voicing these concerns, their care plans did not include any focus, goals, or interventions related to their religious practices or preferences. Facility policy requires that care plans be person-centered, culturally competent, and include measurable objectives and timeframes to meet each resident's medical, mental, and psychosocial needs. The policy also specifies that the care plan should identify the resident's language and communication tools if the resident is non-English speaking, and should incorporate cultural and religious preferences. The failure to include and implement these elements in the care plans for the three residents led to the cited deficiencies.
Failure to Update Discharge Plan to Reflect Resident's Goals
Penalty
Summary
The facility failed to develop a discharge plan that reflected a resident's goals and needs for one resident reviewed for discharge planning. The resident, who had diagnoses including depression, diverticulitis, and obstructive and reflux uropathy, was assessed as having moderate cognitive impairment. The resident's care plan indicated a long-term stay with the goal of remaining in the nursing home, despite the resident expressing a desire to move to assisted living. The care plan interventions included discussing feelings and goals for placement as needed, involving social services, and arranging for discharge if needed, but did not actively reflect the resident's stated goal of transitioning to assisted living. Interviews revealed that the resident had communicated his wish to move to assisted living to the social worker, who became aware of this goal in mid-January after being contacted by an assisted living facility. The social worker acknowledged working with the resident and his representative on enrolling in a managed care organization to facilitate placement. However, the care plan was not updated to reflect the resident's current discharge goal, despite both the social worker and the director of nursing agreeing that the care plan should have been revised as soon as staff became aware of the change in the resident's goals.
Failure to Honor Residents' Religious Preferences and Choices
Penalty
Summary
The facility failed to ensure that two residents, both practicing Muslims, received care and services in accordance with their comprehensive assessments and care plans, specifically regarding their religious and cultural needs. Both residents expressed that their religious practices, such as praying seven times a day and maintaining cleanliness before prayer, were not accommodated. The care plans for these residents did not reflect their religious preferences or primary language, despite these being significant to their well-being. Progress notes and interviews revealed that one resident was unable to pray as required due to not being provided with adequate opportunities for cleanliness, such as daily showers, and a clean space for prayer. The resident also reported not being offered individualized activities or support for her religious practices, and staff were either unaware of her religious needs or had incorrect information about her faith. The second resident, also a practicing Muslim, reported that he was not allowed to use the chapel for prayer and felt that his individual religious needs were not considered by the facility. Staff interviews indicated a lack of awareness regarding the resident's religious preferences, with some staff only noting dietary restrictions such as not eating pork. The activity director and director of nursing both acknowledged that religious preferences should be included in care plans if residents voice such concerns, but these were not documented or addressed in the care plans for either resident. Facility policies required that care and services be provided in accordance with residents' choices, values, and beliefs, and that care plans reflect these preferences. However, the facility did not follow its own policies, as evidenced by the lack of documentation and accommodation of the residents' religious needs. The deficiency was identified through interviews, record reviews, and observations, which consistently showed that the residents' spiritual and cultural needs were not being met as required.
Failure to Provide Timely ADL Assistance and Maintain Resident Dignity
Penalty
Summary
Two residents with significant care needs did not receive appropriate assistance with activities of daily living (ADLs), specifically in the areas of personal hygiene, grooming, and toileting, as required by their care plans. One resident, who was totally dependent on staff for personal hygiene and oral care due to multiple diagnoses including a femur fracture, failure to thrive, prostate cancer, anxiety disorder, and heart failure, was observed in the dining room in pajamas with unkempt hair and long, scraggly whiskers. Documentation for this resident's bathing, grooming, and hygiene was either missing or marked as not applicable for multiple consecutive days, and only the night shift was documenting these cares. The resident expressed dissatisfaction with his appearance and reported needing assistance with shaving and grooming, which was confirmed by staff interviews indicating a lack of clear guidelines on the frequency of shaving and grooming tasks. Another resident, with diagnoses including Parkinson's Disease, neuromuscular bladder dysfunction, muscle weakness, and cognitive impairment, was observed multiple times in soiled clothing and with a strong odor of urine. This resident required two-person assistance with transfers and toileting, as documented in the care plan, and was to be changed every two hours. However, staff interviews revealed that the resident was often left in wet briefs and clothing for extended periods, with some staff admitting that changes were not performed as scheduled, sometimes due to the resident's combative behavior. Documentation of care refusals was inconsistent, with only one refusal recorded in the relevant period, despite staff claims of frequent refusals. Observations and interviews confirmed that both residents did not receive the necessary services to maintain good hygiene, grooming, and dignity as outlined in facility policy and their individualized care plans. Staff failed to provide timely and adequate assistance with toileting and personal care, resulting in one resident being left in urine-soaked clothing and another with unaddressed grooming needs. These failures were corroborated by direct observations, resident interviews, and staff admissions, demonstrating a lack of adherence to established care protocols and policies.
Failure to Follow Physician Orders for Pressure Injury Care
Penalty
Summary
A resident with a stage 4 pressure injury on the left hip did not receive necessary treatment and services consistent with professional standards of practice to promote healing. Physician orders specified that the resident should not be in her wheelchair for more than one hour at a time, must be repositioned every 30 minutes while in the wheelchair, and should not lay on her left hip while in bed. These orders were not incorporated into the resident's care plan or care card, and staff were not consistently aware of or following these specific instructions. Observations by the surveyor revealed that the resident remained in her wheelchair for over an hour without being repositioned, despite verbalizing discomfort. Multiple staff interviews demonstrated inconsistent knowledge of the resident's repositioning requirements, with staff referencing standard protocols or the care card, which did not reflect the individualized physician orders. Staff responses varied, with some stating repositioning should occur every two hours, others indicating twice per shift, and some unaware of the specific restrictions regarding the resident's left hip. The Director of Nursing confirmed that physician orders should be followed as written but was not aware of the specific requirements for this resident. The care plan and care card lacked updates to reflect the physician's orders, and no new interventions were added after a wound infection. The facility was unable to provide a policy regarding pressure injury care when requested by the surveyor. As a result, the resident did not receive care in accordance with physician orders and professional standards, leading to a deficiency finding.
Failure to Provide Adequate Pain Management and Transfer Alternatives
Penalty
Summary
A resident with a history of chronic pain, including diagnoses such as Type 2 Diabetes Mellitus, hemiplegia, osteoarthritis, and rotator cuff pathology, experienced ongoing pain exacerbated by the use of an EZ stand lift for transfers. Despite being cognitively intact and repeatedly expressing that the EZ stand caused significant shoulder pain, the facility did not adequately address her pain needs or seek alternative transfer methods. The resident reported crying multiple times daily during transfers and requested re-evaluation for different transfer options, but received no response from therapy or facility leadership. Facility staff, including CNAs and the social worker, were aware of the resident's pain during transfers, with multiple staff members acknowledging that the EZ stand caused her distress and that she cried during each use. The care plan included interventions to evaluate pain management and check comfort levels, but there was no evidence that the plan was updated or that new interventions were implemented in response to the resident's ongoing complaints. The Director of Nursing and other staff confirmed knowledge of the pain but did not initiate increased pain assessments, care plan revisions, or interdisciplinary team meetings as outlined in facility policy. Medication records showed frequent use of both scheduled and PRN pain medications, and physician notes documented persistent pain despite these interventions. The facility failed to reassess the resident's pain management plan or develop and implement new approaches to transferring, and did not ensure that front line staff were informed of the resident's preferences regarding transfers. As a result, the resident continued to experience daily pain associated with the use of the EZ stand, and her care plan was not revised to address her ongoing needs.
Failure to Assess and Supervise Resident's Use of Lift Chair Resulting in Falls
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for one resident. The resident, who had a history of falls, osteoporosis, depression, and dementia, required substantial to maximum assistance with most activities of daily living and was assessed as cognitively intact. Despite these needs, the facility did not adequately assess or monitor the resident's ability to safely use a lift chair, which was a known risk factor for falls. The resident was first observed sliding out of a recliner, prompting a recommendation from therapy to use non-slip matting. However, after a subsequent fall from the lift chair, the intervention was to unplug the chair due to the resident's lack of safety awareness. The care plan was updated accordingly, but the chair was later plugged back in without documented evidence of a reassessment of the resident's ability to use it safely. This lack of documentation and assessment persisted even after the resident experienced another fall from the lift chair, resulting in a femur fracture. Interviews with facility staff revealed that there was no specific fall prevention education provided to staff during orientation or in the previous six months. Additionally, the facility was unable to provide documentation of discussions or assessments regarding the decision to allow the resident to use the lift chair again. The absence of a thorough assessment and lack of staff education contributed to the resident's repeated falls and injury.
Failure to Follow Prescribed Diet Texture for Resident
Penalty
Summary
The facility failed to follow the prescribed easy to chew (Level 7) diet for a resident with multiple diagnoses, including Parkinson's disease, generalized muscle weakness, reduced mobility, adult failure to thrive, and dysphagia. The resident's care plan and physician orders specified a Level 7: Easy to Chew diet, which is intended for individuals who have difficulty chewing and/or swallowing regular textured foods. Despite these orders, the resident was observed with snacks such as cheese crackers, Cheetos, and potato chips in her room, which are not compliant with the prescribed diet. Interviews with staff revealed that both certified nursing assistants and the speech therapist allowed the resident to have snacks outside of her diet restrictions, citing quality of life and the resident's preferences. The speech therapist acknowledged making exceptions for the resident but did not document these exceptions or communicate them to the interdisciplinary team. The registered dietician confirmed that these snacks were not in compliance with the Level 7 diet and that any quality of life exceptions should have been documented in the care plan, which had not occurred. Further interviews with the resident and her family confirmed that she regularly received and consumed snacks not aligned with her prescribed diet, provided both by staff and family members. The director of nursing acknowledged that the speech therapist's exceptions were not documented and not included in the resident's care plan. There was no evidence of a risk and benefit analysis or an order in the medical record to support deviations from the prescribed diet.
Conflicting Care Plan Entries on Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one resident, resulting in conflicting information regarding the resident's ability to self-administer medication. The resident's care plan contained an undated notation stating that the resident may self-administer scheduled oral medications after set-up, while another intervention dated 05/02/24 indicated that the resident may not self-administer medications and must be observed taking them. Additionally, a focus item in the care plan initiated on 01/02/25 set a goal for the resident to be safe in self-administration of medications. However, review of the resident's orders in the electronic medical record did not reveal any order authorizing self-administration of medication. Interviews with staff revealed further confusion, as an LPN stated she was aware the resident could self-medicate based on a special order banner in the EMR, but was unaware of the conflicting care plan entries. The Director of Nursing acknowledged the presence of conflicting information in the care plan regarding the resident's self-medication status. The resident in question had a history of multiple diagnoses, including malignant neoplasm of the ileum, urinary tract infection, sepsis, acute respiratory failure, diabetes, depression, mild cognitive impairment, and insomnia, and was assessed as cognitively intact.
Failure to Ensure Proper Installation and Testing of Bed Rails
Penalty
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails for four residents, identified as R3, R6, R7, and R8. The deficiency was identified through observation, interviews, and record reviews, revealing that bed rails were installed without conducting a Bed System Measurement Device Test to ensure proper installation and reduce the risk of entrapment. The facility's policy requires that physical devices, including bed rails, be reviewed for safety and used according to the manufacturer's recommendations, with regular inspections to prevent safety hazards. For resident R3, the surveyor observed a gap between the bed rail and the mattress, indicating improper installation. The Maintenance Supervisor (MS C) admitted that a newly hired employee, who had not been trained on the measurement device, was installing bed rails. MS C also acknowledged that several installations had not been tested for entrapment points. The facility provided a Bed System Measurement Device Test for R3 dated after the surveyor's request, with no prior documentation of testing. Similarly, residents R6, R7, and R8 had bed rails installed without prior testing documentation. The facility's records indicated order dates for the bed rails, but no evidence of testing before the surveyor's intervention. The Nursing Home Administrator (NHA A) confirmed that testing should occur upon installation, but the facility lacked documentation of actual installation dates, relying instead on order dates. This oversight in testing and documentation led to the deficiency identified by the surveyors.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, leading to a fall incident. The resident, who was cognitively intact and required assistance from two staff members for bed mobility and transfers, fell out of bed when a CNA attempted to assist her alone. The resident's care plan and Kardex clearly stated the need for two-person assistance, but this was not followed, resulting in the resident sliding off the bed and becoming wedged between the bed and the wall. The incident occurred while the CNA was assisting the resident with toileting, and the resident's head was caught between the bed and the side rail, although she later clarified that her head was lower than the side rail. The facility's failure to ensure all staff were trained and aware of the resident's care plan contributed to the incident. The resident reported that staff frequently assisted her alone, despite the care plan's requirement for two-person assistance, and this practice continued even after the fall. The Nursing Home Administrator was unaware of the frequency of single-staff assistance and acknowledged that not all staff had been educated on following the Kardex. Additionally, several staff members, including the CNA involved in the incident, had not received the necessary education or competency testing as part of the facility's post-event action plan.
Resident Burned by Hot Coffee Due to Lack of Safety Protocols
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents, as evidenced by an incident involving a resident who sustained burns from hot coffee. The resident, who was cognitively intact but had physical impairments including quadriplegia, was served coffee in bed. The coffee was served at a temperature of 185 degrees Fahrenheit, which was not monitored or adjusted for safety. The resident attempted to switch the coffee cup from his left hand to his right hand, which was weaker, resulting in the coffee spilling and causing burns to his right flank and buttocks. The facility did not have a process in place for assessing the safety of serving hot liquids to residents, nor were there any specific care plans addressing the risks associated with hot liquids for this resident. The staff routinely provided the resident with coffee in his personal thermos cup without conducting any safety assessments or monitoring the temperature of the coffee. The incident report and interviews with staff revealed that there was no established protocol for ensuring the safe handling of hot beverages by residents, particularly those with physical impairments. Interviews with staff indicated a lack of awareness and training regarding the risks of serving hot liquids to residents. The facility's policy on food safety and preventing burns was not effectively implemented, as staff were not monitoring the temperatures of hot beverages at the point of service. The absence of a structured process for evaluating residents' ability to safely handle hot liquids contributed to the incident, highlighting a significant oversight in the facility's safety protocols.
Inadequate Monitoring and Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic and antipsychotic medications was free from unnecessary medications. The resident, who was admitted with diagnoses including Alzheimer's Disease and Generalized Anxiety Disorder, was prescribed Seroquel and Lorazepam without an appropriate diagnosis for antipsychotic medication. The facility's policy requires that antipsychotic drugs should not be used unless the resident's medical record clearly indicates specific conditions, which was not the case for this resident. The facility did not adequately track quantitative measurements during behavior tracking, which is necessary to measure the efficacy of medication therapy. The resident's Treatment Administration Record (TAR) showed numerous instances where behavior monitoring and side effect monitoring were not properly documented. Instead of recording the number of episodes or using 'Y' or 'N' to indicate behaviors and side effects, staff frequently used 'X' or check marks, which are not appropriate according to the facility's Director of Nursing. Interviews with staff, including RNs, CNAs, and the DON, revealed that the resident's behaviors were not persistent or harmful to themselves or others, contradicting the need for antipsychotic medication. The staff indicated that the resident could be verbally aggressive but was easily redirected and not physically aggressive. The lack of proper documentation and monitoring of the resident's behaviors and medication side effects contributed to the deficiency identified by the surveyors.
Inadequate Supervision and Dietary Compliance Leads to Choking Incidents
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to dietary restrictions for a resident with a history of dysphagia and aspiration events. The resident, who has diagnoses including Parkinson's Disease, dementia, and chronic dysphagia, experienced two choking incidents within a month. On the first occasion, the resident choked on a hot dog, requiring the Heimlich maneuver and hospitalization for acute hypoxic respiratory failure and aspiration pneumonitis. Despite this incident, the facility did not adequately supervise the resident's meals, leading to a second choking event. During the second incident, the resident was served a bowl of honeydew melon, which was not consistent with the prescribed Level 6 soft and bite-sized diet. This resulted in another aspiration event and subsequent hospitalization. Interviews with staff revealed a lack of clarity and responsibility regarding the verification of meal tickets and the appropriateness of food served. The CNA and dietary staff were both identified as responsible for ensuring the correct diet was served, yet the resident received inappropriate food items, leading to the choking incident. The facility's care plan and dietary restrictions for the resident were not followed, contributing to the immediate jeopardy situation. The resident's care plan indicated a need for supervision during meals and specific dietary restrictions, which were not adhered to. Staff interviews highlighted issues with communication and training regarding diet textures and meal ticket verification, which were factors in the deficient practice.
Removal Plan
- The facility will complete mock drills and competency tests for all licensed nursing staff including how to support a resident with partial obstructed airway, choking, Heimlich etc.
- The facility will educate nursing, culinary and activities staff on altered diets/IDDSI. The training will include how to determine foods/fluids safe to consume on prescribed/altered diets. A competency will be completed following education.
- The facility will provide instruction to culinary, activities and nursing staff on where to find a resident's diet.
- The facility has created a system where all meal tray cards for residents on an altered diet will be printed in a different orientation format, so it will be easily recognizable to staff to determine the appropriate diet and food/fluids safe to consume per the prescribed diet.
- The facility will ensure that a licensed nurse is assigned to each dining room.
- The facility will audit all resident diet orders, tray cards, care plan and Kardex to ensure correct orders and that orders match and include ST recommendations for residents who have been on ST caseload.
- The facility will complete meal audits to ensure receiving proper diet breakfast, lunch, and dinner in 2 dining rooms each meal.
- The facility will audit all employee records for licensed nurses to ensure CPR certification. The facility will ensure a licensed nurse is assigned to each dining room during all meals.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) had documented performance reviews conducted annually, as required by the facility's policy. The policy, titled Competency Assessment and Validation, mandates that competency should be assessed annually to ensure all employees are competent in their assigned responsibilities. However, the surveyor's review of the CNA performance review documentation revealed that the last evaluations for CNAs J, K, and L were conducted in 2022, despite their employment at the facility for over a year. Specifically, CNA J was last reviewed on April 18, 2022, CNA K on April 24, 2022, and CNA L on February 27, 2022. During an interview with the facility's new Nursing Home Administrator (NHA M), Chief Executive Officer (CEO N), and Regional Director (RD O), it was indicated that the facility's practice was to conduct CNA evaluations every three years, contrary to the annual requirement stated in the policy. The facility provided the most recent evaluations from 2022 but could not provide any additional documentation to support compliance with the annual review requirement. This discrepancy between the facility's policy and practice led to the deficiency identified by the surveyor.
Failure to Notify Physician of Medication Unavailability
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a need to alter treatment, specifically for a resident who was not administered a prescribed medication. The resident, who was admitted with diagnoses including Vitamin B Deficiency, Multiple Sclerosis, and Muscle Weakness, had an order for Vitamin B Complex-C Oral Capsule to be taken daily. However, the medication was not available from 6/13/24 onwards, and the facility did not notify the resident's physician about this issue. The facility's policy requires immediate notification of the physician in cases of significant treatment alterations, but this was not adhered to. The Assistant Director of Nursing (ADON) was informed of the medication error but did not notify the physician. The Director of Nursing (DON) expected the physician to be informed and the medication to be obtained within 48 hours, which did not occur. The failure to notify the physician and obtain the medication as per the facility's policy led to the deficiency identified by the surveyors.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure the prompt resolution of a grievance reported by a resident, identified as R8, who is cognitively intact with a BIMS score of 15 and has medical conditions including diabetes, heart failure, and reduced mobility. R8 reported an incident where an agency CNA left her room without setting up her meal, leaving her unable to eat. R8 expressed feelings of sadness and vulnerability due to the incident. The charge nurse, RN C, was informed of the situation and reported it to the Director of Nursing (DON B) via text message. However, the grievance was not followed up on by DON B, and it was not filed as a formal grievance as required by the facility's policy. The incident occurred during dinner time when CNA E left R8's room to retrieve a clothing protector, and R8 allegedly called CNA E a derogatory name. CNA D intervened, assisted R8 with her meal setup, and reported the incident to RN C. Despite these actions, the facility's grievance policy, which mandates prompt resolution and communication with the resident, was not adhered to, as DON B did not take further action to address the grievance. This lack of follow-up and formal documentation of the grievance constitutes a deficiency in the facility's grievance handling process.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a resident to the State Agency as required by state and federal regulations. The incident involved a resident whose daughter emailed the Nursing Home Administrator (NHA) alleging that a Certified Nursing Assistant (CNA) was yelling at her mother. According to the facility's Abuse, Neglect, and Exploitation Policy and Procedure, such allegations must be reported immediately to the administrator and the State Agency within two hours of forming the suspicion. However, the facility did not adhere to this policy. The grievance was documented in the facility's Grievance Log, indicating that the NHA reached out to the resident's daughter for more details about the incident, such as the date, time, and witnesses. The daughter did not respond to the NHA's request for additional information, leading the NHA to close the grievance due to a lack of information. During an interview with a surveyor, the NHA acknowledged that the allegation of yelling constituted verbal abuse and should have been reported, but it was not.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse involving two residents. For one resident, an allegation of neglect was reported, indicating that care was not provided during the night shift, resulting in the resident being found soaked with urine. The investigation was incomplete as it did not include interviews with day shift staff or other residents, and there was no documentation of investigative procedures for non-interviewable residents. The Director of Nursing acknowledged that a thorough investigation was not conducted. In another case, a grievance was filed by a resident's daughter, alleging verbal abuse by a CNA. The Nursing Home Administrator initially closed the grievance due to a lack of response from the complainant. However, upon further review, it was found that some investigation had been conducted, including staff interviews and an interview with the resident. Despite this, there was no follow-up with other residents who might not be able to voice their concerns, and the grievance log was not updated to reflect the investigation. The facility's policy requires timely and thorough investigations of all abuse allegations, but these incidents demonstrate a failure to adhere to these procedures. The lack of comprehensive investigations and documentation highlights deficiencies in the facility's response to abuse allegations, as confirmed by interviews with the Director of Nursing and the Nursing Home Administrator.
Failure to Prevent and Manage Pressure Injury in Resident
Penalty
Summary
The facility failed to implement professional standards of practice to prevent and manage pressure injuries for a resident identified as R3, who was at risk for pressure injuries due to her medical conditions, including Type 2 Diabetes Mellitus. Despite being cognitively intact and having a Braden Scale score indicating risk, the facility did not include daily diabetic foot checks in R3's physician orders. The care plan for R3 noted the risk for skin integrity issues but did not adequately address the specific needs related to her condition. R3 developed a pressure injury on her left foot bunion, which was initially noted as a red, blanchable area. Over time, the condition worsened, leading to an open wound that became infected, necessitating the use of oral antibiotics. The facility's documentation showed that interventions were not promptly implemented when the reddened area was first observed. The facility also failed to assess the cause of the redness and did not evaluate R3's footwear, which was later identified as a contributing factor to the injury. Interviews with nursing staff and the Director of Nursing revealed that there was a lack of immediate intervention and assessment regarding R3's condition. The staff acknowledged that interventions should have been put in place earlier to prevent the development of the pressure injury. The facility's oversight in not conducting daily diabetic foot checks and not addressing the footwear issue contributed to the development and subsequent infection of the pressure injury on R3's bunion.
Failure to Provide Daily Diabetic Foot Care
Penalty
Summary
The facility failed to provide diabetic foot care in accordance with professional standards of practice for a resident with Type 2 Diabetes Mellitus. The facility's policy, revised in October 2022, mandates daily foot care for diabetic residents to maintain mobility and foot health. However, the resident in question did not have a physician order for daily diabetic foot checks, which resulted in the absence of this task on the Treatment Administration Record (TAR). Consequently, the nursing staff did not perform or document daily foot checks for the resident. Interviews with nursing staff revealed that diabetic foot checks were only completed if they appeared on the TAR, which requires a physician's order. The Director of Nursing (DON) acknowledged that foot checks were conducted weekly during routine skin checks on shower days, contrary to the facility's policy. The DON expressed skepticism about the feasibility of daily checks and was unable to provide an alternative policy to the surveyor.
Failure to Maintain 1:1 Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for a resident who was supposed to be under 1:1 supervision. The resident, who had been admitted with diagnoses including frontotemporal neurocognitive disorder and muscle weakness, had recently returned from a hospital stay and was noted to wander around the unit. Despite the need for close supervision, the resident's care plan did not include information about 1:1 supervision. On the day of the incident, a CNA assigned to supervise the resident left the resident unattended, resulting in the resident falling in the hallway. During the survey, the RN on duty confirmed that the resident was supposed to be under 1:1 supervision and that the CNA should not have left the resident alone. The CNA acknowledged that she should have stayed with the resident until someone else could take over. The Director of Nursing also confirmed that the resident was considered to be on 1:1 supervision and that staff should not leave such residents unattended. This lack of supervision led to the resident's fall, highlighting a failure in maintaining the required level of care and supervision for the resident's safety.
Failure to Provide Required Medication to Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R5, who had a physician's order for Vitamin B Complex-C Oral Capsule. The medication was not available for administration from 6/11/24 and from 6/13/24 through 6/27/24. R5 was admitted with diagnoses including Vitamin B Deficiency, Multiple Sclerosis, and Muscle Weakness, and had an order to receive the supplement daily. The facility's policy requires the provision of pharmaceutical services to ensure the accurate acquisition, receipt, dispensing, and administering of all drugs and biologicals. Interviews with facility staff revealed a breakdown in communication and procedure regarding the medication's availability. RN F reported the issue to the nurse manager and ADON G, indicating that the medication was not provided by the pharmacy as expected. ADON G confirmed a medication error report was completed and noted that the pharmacy claimed they did not have an order for the medication, despite previous orders. DON B indicated multiple attempts to communicate with the pharmacy to resolve the issue, but the medication was still not received. This deficiency highlights a failure in the facility's pharmaceutical service procedures, impacting the resident's care.
Inadequate Infection Prevention and Control Program
Penalty
Summary
The facility has not established an effective infection prevention and control program, which has the potential to affect all 106 residents. The facility failed to ensure daily infection control surveillance for staff, resulting in incomplete infection control line lists for both staff and residents. Additionally, the facility's monthly infection control rates were not calculated according to current standards of practice, and the March 2024 COVID outbreak summary was found to be incomplete and inaccurate. During an interview, the LPN/IP indicated that the facility does not have documentation of daily surveillance for staff and was unsure when this was last completed. The staff call-in logs reviewed by surveyors were found to be incomplete, with many entries lacking symptomology. This lack of daily surveillance prevents the facility from ensuring correct exclusionary criteria, return-to-work dates, and the ability to prevent, identify, report, investigate, and control infections and communicable diseases. The infection control line lists for residents and staff were also found to be incomplete. For example, the Resident LTC Respiratory Surveillance Line List for January 2024 contained missing information such as the type of test ordered, pathogen detected, and symptom resolution. Similarly, the Staff LTC Respiratory Surveillance Line List for January and February 2024 lacked critical information such as the date last worked, type of test ordered, pathogen detected, and return-to-work dates. Additionally, the March 2024 COVID Outbreak Summary did not match the line list information, indicating that six staff members were not identified in the outbreak summary. Furthermore, an observation revealed that a CNA did not disinfect a resident's bedside table after placing a urinal on it, posing a risk of cross-contamination. The facility's infection prevention and control program was found to be lacking in several areas, including daily surveillance, accurate and complete line lists, and proper calculation of infection control rates. These deficiencies highlight the need for a more organized and effective infection control program to ensure the safety and well-being of residents and staff.
Failure to Complete PASARR Level II Screens
Penalty
Summary
The facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II for residents who stayed longer than 30 days, despite initial exemptions. This deficiency affected four residents who had serious mental illnesses or intellectual disabilities and were on psychotropic medications. The facility's policy required a PASARR Level I screen for all new admissions and a Level II screen if the stay exceeded 30 days, but this was not adhered to for the residents in question. Resident R41, with diagnoses including Generalized Anxiety Disorder and Depression, and on Risperidone, did not have a PASARR Level II screen completed after exceeding the 30-day exemption. Similarly, Resident R89, with Major Depressive Disorder and Anxiety Disorder, and on Duloxetine, also lacked a PASARR Level II screen. Resident R36, with Major Depressive Disorder and on Lexapro, and Resident R103, with bipolar disorder and on multiple psychotropic medications, were also not screened as required. The Director of Nursing indicated a change in responsibility for completing PASARR assessments led to these oversights, and the Nursing Home Administrator acknowledged the deficiency, noting a gap in social worker staffing.
Lack of Adequate Activity Program for Residents
Penalty
Summary
The facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This deficiency affected seven residents who voiced concerns during the Resident Council about the lack of activities, particularly on weekends and evenings. The facility's policy, issued in February 2021, mandates that activities should be appropriate, stimulating, and promote the well-being of residents, considering their individual differences and interests. However, the facility's activity schedule showed limited activities on Saturdays and none on Sundays, failing to meet these requirements. Residents R41, R79, R24, R42, R53, R22, and R59 expressed dissatisfaction with the activity program, noting that there were only one-hour activities on Saturdays and no activities on Sundays. They specifically mentioned missing church services on Sundays, which they used to attend with their families. The activity staff, including the Activity Aide and Activity Director, confirmed the limited scheduling and acknowledged the residents' concerns. They mentioned efforts to find volunteers to lead weekend activities but had not succeeded yet. The Nursing Home Administrator was aware of the residents' complaints and agreed that the activity staff should offer more activities during evenings and weekends. Despite this awareness, no changes had been implemented to address the deficiency. The facility's current activity schedule and staffing did not support the residents' needs for more frequent and varied activities, particularly on weekends and evenings, leading to the deficiency noted by the surveyors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled in accordance with currently accepted professional practices. In one of the medication rooms and several medication carts, surveyors observed multiple instances of undated, open stock medications, medications that should have been refrigerated but were not, and medications with illegible expiration dates. Additionally, different medication administration routes were co-mingled in the same bag, and some medications were found without any labels or resident identification. In one instance, an open vial of Tuberculin purified protein was found without a documented open date, and the RN was unable to state how long the vial had been open. Similarly, a bottle of Florajen was found without an open date or a date indicating when it was removed from the refrigerator. Other examples included undated eye drops, nasal sprays without resident labels, and medications stored together that should have been separated according to their administration routes. Further observations revealed expired medications, such as Latanoprost eye drops and Fluticasone nasal spray, which were not discarded after the recommended period. Additionally, some medications requiring refrigeration, like Promethegan suppositories, were found in medication carts instead of being stored in the refrigerator. The Director of Nursing confirmed that these practices were not in line with the facility's medication storage policy and manufacturer recommendations.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility did not adhere to its antibiotic stewardship program, resulting in inappropriate antibiotic use for several residents. One resident continued an antibiotic for three days without an appropriate indication, and another was ordered and took an antibiotic without meeting the infection criteria. Additionally, a third resident was given an antibiotic before test results were returned and continued to take it despite the lack of appropriate indications for its use. A fourth resident received a prophylactic antibiotic for several months without a clear rationale or end date indicated. The facility's policy on infection prevention and control, which includes an antibiotic stewardship program, was not followed. The Licensed Practical Nurse/Infection Preventionist (LPN/IP) did not always document discussions with providers regarding the necessity of antibiotics, and in some cases, did not contact the provider at all. This led to residents receiving antibiotics without meeting the infection criteria or without proper documentation and rationale for their use. Interviews with staff revealed that there were lapses in following up on antibiotic orders and clarifying the duration of antibiotic use. The Director of Nursing (DON) and other staff members acknowledged that they did not always ensure that antibiotics were prescribed and continued based on appropriate indications and current standards of practice. This lack of adherence to the antibiotic stewardship program resulted in unnecessary and prolonged antibiotic use for the residents involved.
Resident Served Cold Food
Penalty
Summary
The facility did not ensure that food and drink were palatable, attractive, and at a safe and appetizing temperature for one resident observed during dining. The resident, who has dementia and requires moderate assistance for eating, was observed sitting at a dining room table asleep in her wheelchair with a plate of food in front of her. The food remained in front of the resident for approximately 34 minutes before a CNA began feeding her. At that time, the surveyor requested the temperature of the lasagna, which was found to be 113 degrees Fahrenheit. The facility staff then replaced the resident's food.
Failure to Report Alleged Abuse and Missing Narcotics
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the administrator and other officials, and that residents were protected during the facility's investigation. In the case of one resident, the facility did not suspend the staff member named in the abuse allegation as required by the facility's Abuse Policy and Procedure. The Director of Nursing (DON) and Nursing Home Administrator (NHA) determined that the incident was a customer service issue rather than abuse, despite the complainant using the term 'abuse.' The staff member continued to work during the investigation, although not with the resident involved in the allegation. In another instance, the facility failed to report a missing narcotic pain patch for a resident. The nurse who discovered the missing patch reported it to the nurse manager on duty, but the information was not relayed to the DON or the administrator. The DON confirmed that such incidents should be reported up the chain of command and could be considered potential misappropriation or diversion. The facility did not report the missing narcotic patch to the state agency until the surveyors brought it to their attention. These deficiencies highlight the facility's failure to follow its own policies and procedures for handling allegations of abuse and missing narcotics. The lack of immediate reporting and appropriate protective measures for residents during investigations compromised the facility's ability to address and resolve these serious issues effectively.
Failure to Investigate Missing Narcotic Pain Patch
Penalty
Summary
The facility failed to investigate a potential misappropriation of a narcotic medication for a resident (R41) who was reviewed for abuse. On 4/17/24, the facility became aware of a potential misappropriation involving R41's narcotic pain patch, but this was not reported to the Nursing Home Administrator for an investigation to be completed. The facility's policy on Abuse, Neglect, and Exploitation, reviewed in November 2023, mandates that any suspected abuse, neglect, or exploitation be immediately reported to the administrator and thoroughly investigated. However, this procedure was not followed in the case of R41's missing Buprenorphine Transdermal Patch, a narcotic medication. R41, who was admitted to the facility with diagnoses including pain in the right knee, other congenital malformations, and unspecified convulsions, has a moderate cognitive impairment as indicated by a BIMS score of 10. On 4/17/24, a nurse's note documented that R41's patch was not present that morning. Despite this, no investigation was initiated. Interviews with the RN who authored the note and the DON confirmed that the missing patch should have been investigated as potential misappropriation or diversion but was not. The NHA acknowledged the concern during the exit conference, and it was noted that the facility did not complete an investigation into the missing patch, although they had submitted a report to the state agency regarding the incident.
Failure to Complete Discharge MDS Assessment for Deceased Resident
Penalty
Summary
The facility did not ensure comprehensive assessments were completed as required for one of the three closed records reviewed for Minimum Data Set (MDS) assessments. Specifically, the facility failed to complete a discharge MDS assessment for a resident (R12) who passed away. The facility's policy, which aligns with the Centers for Medicare and Medicaid Services' RAI Manual, mandates that a discharge MDS assessment be completed when a resident dies. However, upon review of R12's medical record, it was noted that no discharge MDS was completed upon the resident's passing. R12 was admitted to the facility with diagnoses including Alzheimer's disease and was receiving end-of-life care by the facility and a hospice agency. The resident's nurse notes indicated that a hospice RN formally pronounced the resident as deceased and contacted the family and funeral home. Despite this, the Director of Nursing (DON) confirmed that R12's medical record did not contain the required discharge MDS. The DON indicated that the facility contracts with an external company to complete MDS assessments and would need to contact them to rectify the omission.
Inaccurate MDS Coding for CPAP Usage
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the resident's status for one resident (R43) out of a total sample of 27. Specifically, R43's Minimum Data Set (MDS) dated [DATE] did not correctly code her Continuous Positive Airway Pressure (CPAP) usage. The facility does not have a specific Policy and Procedure for MDS accuracy and follows the Resident Assessment Instrument (RAI) manual. According to the RAI manual, the assessment must accurately reflect the resident's status. R43's physician orders indicated CPAP usage starting from 6/16/22, but the MDS incorrectly marked 'NO' for CPAP usage. Upon review, the MDS Coordinator confirmed the error and stated that a modification would be needed to correct it. The Nursing Home Administrator also confirmed that MDS assessments are expected to be completed accurately.
Failure to Document Weekly Wound Measurements
Penalty
Summary
The facility did not ensure treatment and care in accordance with professional standards of practice for a resident with a wound on the left stump. The resident, who is cognitively intact and has diagnoses including Acquired Absence of Left Leg, Peripheral Vascular Disease, and Multiple Sclerosis, did not have weekly measurements documented for the wound as required. The facility's policy on Pressure Ulcer/Skin Integrity mandates routine ongoing documentation of the resident's skin condition and response to care, but it does not specify detailed parameters for wound assessment. Despite this, both the wound nurse and the Director of Nursing (DON) acknowledged that weekly measurements should be conducted for any open wound. The surveyor's review of the Weekly Skin Check Tool and nursing progress notes revealed that from the time the wound was first noted on 2/8/24 until 5/2/24, there should have been 12 weekly wound measurements. However, only 3 measurements were documented. Interviews with the wound nurse and the DON confirmed the lack of weekly measurements, indicating a failure to adhere to the facility's policy and professional standards of practice. This deficiency was identified through observations, staff interviews, and record reviews conducted by the surveyors.
Significant Medication Error Due to Unavailability of Antipsychotic Medication
Penalty
Summary
The facility did not ensure that residents are free of significant medication errors, as evidenced by the case of a resident (R19) who missed two doses of an antipsychotic medication, Pimozide, in April. The resident, who has diagnoses including Schizophrenia, Major Depressive Disorder, and Insomnia, had a physician order for Pimozide 5mg to be taken once daily. The medication was not administered on two consecutive days, 4/28 and 4/29, due to it being unavailable. The facility's medication error log, Medication Administration Record (MAR), and Nursing Progress Notes confirmed the missed doses and documented the follow-up actions taken, including re-ordering the medication and notifying the nurse manager and provider. Interviews with facility staff, including a Registered Nurse (RN K), the Assistant Director of Nursing (ADON S), and the Director of Nursing (DON B), revealed that the medication was not available due to an insurance issue and that the facility's protocol for handling such situations was not fully adhered to. The staff indicated that the pharmacy was contacted, but the medication could not be delivered in time. The facility's policy requires that if a medication is not available, the pharmacy should be contacted immediately, and the provider should be notified if the medication is still unavailable after the first missed dose. The failure to follow these procedures resulted in the resident missing two doses of a vital medication.
Failure to Document and Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure proper documentation and administration of pneumococcal vaccinations for three residents. Resident R41 had a signed consent form for the Prevnar 20 vaccine, but there was no evidence of the vaccine being administered. During an interview, the LPN/Infection Preventionist (IP) confirmed that the immunization should have been given but could not locate any documentation of its administration. Resident R63's medical records lacked any documentation of pneumococcal vaccination, consent, or declination. The Wisconsin Immunization Registry (WIR) also did not contain any pneumococcal vaccination dates for R63, and the LPN/IP was unable to provide any additional information regarding the resident's vaccination status. Similarly, Resident R102's records did not contain documentation of consent or declination for pneumococcal vaccination. Although the WIR showed a previous administration of the Prevnar 13 vaccine, there was no follow-up documentation for the Pneumococcal 23 vaccine, and the LPN/IP admitted to not following up with the resident's Power of Attorney for consent. The facility's policy on pneumococcal immunizations states that all residents should be encouraged to obtain the vaccines unless contraindicated and that a system should be in place to offer these vaccines at the time of admission. The policy also requires that residents or their legal representatives receive education on the benefits and risks of the immunizations and that the medical record be updated to reflect the immunizations provided, education given, refusals, and any medical contraindications. The lack of documentation and follow-up in the cases of R41, R63, and R102 indicates a failure to adhere to these policies, resulting in incomplete records and potential gaps in resident care.
Inaccurate and Inaccessible Nurse Staffing Postings
Penalty
Summary
The facility did not ensure the nurse staffing posting was accurate and posted in an accessible area, potentially affecting the census of 106 residents. Multiple daily staff postings did not reflect the actual hours of the nursing staff. The postings were placed high on a wall with small text, making them difficult to read. Specific discrepancies were noted on several dates where the Daily Staff Roster did not match the Daily Census/Staffing document. For example, on 4/17/24, the roster did not reflect that an LPN was scheduled as the nurse manager for the day shift, and the night shift showed discrepancies in the number of LPNs scheduled. Similar inconsistencies were observed on 4/18/24, 4/19/24, and 4/27/24, where the number of CNAs and LPNs listed on the postings did not match the actual schedule. These inaccuracies were confirmed through interviews with the scheduler and residents, who also indicated that the postings were difficult to read due to their location and small text size. On 5/2/24, the surveyor interviewed the scheduler, who confirmed that the postings should reflect the actual schedule and be updated accordingly. The scheduler acknowledged the discrepancies and provided explanations for the mismatches, such as call-ins and errors in updating the postings. Residents interviewed also confirmed that they could not read the postings due to their height and small text. The scheduler admitted that the postings were created the day before and sent to the night nurse, with charge nurses responsible for updating them by 2 PM on the day of the posting. However, this process was not consistently followed, leading to the observed discrepancies and accessibility issues.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of six residents, resulting in multiple instances where medications were not administered as ordered. Specifically, residents R4, R7, R18, and R21 did not receive their medications as prescribed. For example, R4 did not receive Cefprozil for COVID-19 on one occasion, and R7 missed doses of Simethicone and Calcium Carbonate due to medication unavailability. R18 also missed a dose of Senna, with facility documentation indicating that the medication was not available. The Vice President of Clinical Services (VPCS) acknowledged that there was a misunderstanding during the transition from an in-house pharmacy to an outside pharmacy, leading to the unavailability of over-the-counter medications on specific dates. The Director of Nursing (DON) did not consider the undispensed medications to be a medication error and stated that the facility's channels to ensure timely medication administration failed on those dates. Resident R5, who has diagnoses including diastolic heart failure and chronic kidney disease, did not receive a scheduled dose of Lasix on one occasion. The Medication Administration Record (MAR) showed an empty box where the medication should have been signed out. R5's care plan indicated a focus on heart circulation and the need for medications, labs, and treatments as ordered. Similarly, R13, who has diagnoses including hypomagnesemia and insomnia, missed multiple doses of various medications, including Tylenol, Claritin, melatonin, trazodone, calcium, and magnesium. The MAR indicated that these medications were either not available or not administered, with no documentation in the nurse progress notes explaining why the medications were not given or what was done to attempt to administer them. Resident R21, diagnosed with bipolar disorder, also missed doses of critical medications. The MAR showed that lamotrigine and Seroquel were not administered on specific dates, with no indication in the nurse progress notes explaining the reasons or actions taken. The care plan for R21 included goals and interventions related to mood and behavior management, as well as psychotropic drug use, but the failure to administer the medications as ordered was not addressed. Interviews with the VPCS and DON revealed that the facility's process for handling unavailable medications was not followed, leading to these deficiencies in pharmaceutical services.
Failure to Provide Support Person for Resident's Medical Appointments
Penalty
Summary
The facility did not ensure that a resident (R1) was treated with dignity and respect by failing to provide a support person to assist her in attending medically necessary physician appointments. R1, who has multiple medical conditions including dementia, multiple sclerosis, and muscle weakness, was admitted to the facility with an Activated Power of Attorney for Health Care (APOAHC) who resides out of the country. Despite R1 being cognitively intact, the facility canceled her ophthalmology appointment because no support person was available to accompany her, leading to significant distress and agitation for R1. The facility's lack of a policy regarding appointments, transportation, and supervision contributed to this issue, as evidenced by the incident on 2/13/24 when R1 attempted to attend her appointment alone and became upset when redirected by staff. The facility's Nursing Home Administrator (NHA) communicated with R1's APOAHC, stating that the facility does not provide support persons for residents attending outside medical appointments and that it is the responsibility of the resident's family or friends. This policy was enforced despite R1's APOAHC living out of the country and being unable to provide a support person. The NHA also mentioned that the facility had been in communication with various parties, including R1's physician and managed care organization, who agreed that R1 needed a support person for safety reasons. However, the facility did not take responsibility for ensuring R1's safety during her appointments, leading to the deficiency. The surveyor's interview with the NHA revealed that the facility had previously sent staff to accompany R1 to appointments but decided to stop this practice, citing that it was not done for other residents. The NHA was unaware that it was the facility's responsibility to ensure R1's safety and honor her and her APOAHC's choice of physicians. The facility's failure to provide a support person for R1's medical appointments, despite her APOAHC's inability to do so, resulted in a deficiency in treating the resident with dignity and respect and ensuring her safety during necessary medical visits.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility did not make prompt efforts to resolve a grievance expressed by the Activated Power of Attorney for Healthcare (APOAHC) of a resident (R1). The APOAHC raised concerns to the previous Director of Nursing (DON) regarding the treatment of R1 by a Certified Nursing Assistant (CNA). However, the facility failed to document the grievance, investigate the allegations, or record any details about the incident. The facility's grievance log for the relevant period did not contain any entries related to R1's complaint, and no documentation of an investigation or statements was found. The Nursing Home Administrator (NHA) confirmed that the grievance should have been documented and investigated thoroughly, but no such records were available. R1, who was admitted with multiple diagnoses including dementia and multiple sclerosis, did not recall the concern when interviewed by the surveyor. The accused CNA is no longer employed at the facility, but the lack of documentation and investigation remains a significant issue. The facility's policy and procedure on the grievance process, revised in November 2022, stipulates that residents have the right to voice grievances without fear of reprisal and that the facility must make prompt efforts to resolve such grievances. The policy also requires the Executive Director to oversee the grievance process, including receiving, tracking, and investigating grievances, and maintaining records for three years. Despite these requirements, the facility did not adhere to its policy in handling the grievance related to R1, resulting in a deficiency noted by the surveyor.
Failure to Update Care Plan for Resident Requiring Support Person
Penalty
Summary
The facility did not ensure that care plans were reviewed and revised for a resident who required a support person while attending appointments outside the facility. The resident, who was admitted on 6/16/22 with diagnoses including dementia, multiple sclerosis, and muscle weakness, was found to be cognitively intact based on a Minimum Data Set (MDS) assessment. Despite being incapacitated since 8/6/21 and having an activated Power of Attorney for Health Care (APOAHC) who lives out of the country, the resident's care plan was not updated to reflect the need for a support person during external appointments. On 2/13/24, the resident attempted to leave the facility for an appointment and became upset when redirected by staff, demonstrating distress and agitation. The Nursing Home Administrator confirmed that the need for a support person was identified on 2/13/23, but the care plan was not updated accordingly. This oversight was identified during a survey, highlighting the facility's failure to revise the care plan to address the resident's needs adequately.
Failure to Provide Proper Incontinence Care
Penalty
Summary
The facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADLs) received the necessary services for assistance with incontinence care. Specifically, three residents (R16, R23, and R24) were found to be using double incontinence briefs or additional incontinence products without proper care planning or adherence to facility policy. This practice was observed during interviews and care observations, where residents and staff confirmed the use of double briefs due to the residents being heavy wetters. However, the facility's Director of Nursing (DON) indicated that double briefing is not allowed and is not standard practice. Resident R16, who has diagnoses including hemiplegia, urinary incontinence, and a history of urinary tract infections, reported that she is double briefed almost every night. Similarly, Resident R23, who has functional and urge incontinence, was observed with a blue liner and pullup during morning care, and staff confirmed that double briefing occurs despite it not being care planned. Resident R24, who has urge incontinence and dementia, also reported requesting double briefs due to being a heavy wetter, and staff acknowledged that some comply with these requests even though it is against policy. Interviews with multiple CNAs revealed that double briefing is a common practice for residents who are heavy wetters, despite the lack of care planning and the facility's policy against it. The DON confirmed that staff should not use double briefs and that residents should be toileted more frequently if they are heavy wetters. The facility was unable to provide a policy on incontinence products, further highlighting the inconsistency in care practices and the lack of adherence to established protocols.
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Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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