Complete Care At Ridgewood Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Racine, Wisconsin.
- Location
- 3205 Wood Rd, Racine, Wisconsin 53406
- CMS Provider Number
- 525608
- Inspections on file
- 32
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Complete Care At Ridgewood Llc during CMS and state inspections, most recent first.
A resident admitted under a 30‑day PASARR exemption remained in the facility without a required new Level 1 PASARR being completed after the exemption period ended, despite multiple new psychiatric diagnoses and psychotropic medication changes. The resident’s MDS documented severely impaired decision‑making and moderate depressive symptoms, and diagnoses of Unspecified Mood Affective Disorder and Adjustment Disorder with Depressed Mood were added, along with Paroxetine for anger and sexual inappropriateness and later Depakote Sprinkles and PRN Ativan for behaviors. Facility policy required screening of residents who stay beyond 30 days and referral to the state authority when serious mental disorder is present or newly evident, and assigned the Social Services Director responsibility for tracking PASARR status, but the PASARR process was not initiated and the state authority was not notified of the significant change in mental illness. The SSD reported not being involved with PASARR processing or knowing who completes new Level 1 screenings, and the DON confirmed that a new Level 1 PASARR had not been completed when the changes occurred.
A resident with multiple cardiac and pulmonary conditions was readmitted from the hospital with a [NAME] cardiac event monitor placed for 7–14 days to evaluate atrial flutter with rapid ventricular response. Although initial notes by nursing staff and an NP confirmed the monitor was in place on the left chest and to be maintained for the ordered duration, facility staff did not enter a physician order for the monitor, did not add it as an intervention to the cardiovascular care plan, and did not transcribe it to the MAR or treatment record. Review of the 24-hour board showed only sporadic references to the monitor, with many shifts lacking any documentation that it was in place and functioning, and no documentation on the day of discharge. Interviews with an LPN and the ADON revealed uncertainty and inconsistency about how to document and care plan such monitors, supporting the finding that the resident did not receive care in accordance with professional standards and physician orders.
Two residents with existing pressure injuries did not receive care consistent with professional standards and facility policy. One resident admitted with an unstageable sacral pressure injury, later documented by a wound MD as stage 3 and then unstageable, was incorrectly down-staged as stage 2 on two separate readmissions, and staff failed to update MD orders when the wound MD changed the strength of Dakin’s solution, resulting in the wrong solution being used on two occasions. Another resident with severe cognitive impairment and an unstageable left heel pressure injury had a care plan requiring heel boots while in bed, yet was repeatedly observed in bed without heel boots and with heels resting on the mattress, even after the wound MD emphasized the need to keep the heels off the bed and staff acknowledged the resident frequently kicked off the boots and that no increased monitoring or reapproach strategy was in place.
A resident with dementia, severely impaired decision-making, and depressive symptoms exhibited ongoing sexually inappropriate behaviors toward female staff and later toward a female peer, including grabbing, exposure, and persistent sexual comments. Over several months, RNs, LPNs, a psych NP, and a psychologist documented chronic sexual disinhibition, poor impulse control, and limited response to redirection, while psych providers recommended close behavioral monitoring, supervision, and safety precautions. However, the facility’s TARs showed no targeted behaviors, staff were unaware of a "cares in pairs" intervention, and psychiatric recommendations were not incorporated into the care plan until after a resident-to-resident sexual incident in a public dining area. The facility did not complete a timely assessment of the resident’s capacity to consent to sexual activity and did not initiate the PASARR process despite significant changes in mental health diagnoses and psychotropic treatment. The Social Services Director reported not reviewing psych notes for care planning and not participating in PASARR coordination, resulting in a failure to provide required medically-related social services to support the resident’s highest practicable physical, mental, and psychosocial well-being.
A resident with hemiplegia and hemiparesis, cognitively intact and ordered a regular diet with mechanical soft texture, was repeatedly provided Doritos tortilla chips despite being on a mechanically soft diet. During a meal observation, the resident had multiple bags of Doritos at the bedside and confirmed that staff regularly brought Doritos and Pepsi. The cook verified the mechanically soft diet order, while the Activity Director explained that activities staff, using a daily allowance, purchased and gave the resident two bags of Doritos each day, with the family also supplying chips. The RD and SLP stated Doritos are not allowed on a mechanically soft diet and that a signed diet waiver with documented risk/benefit discussion is required when a resident chooses non-compliant foods, but no such waiver or documentation was found in the record at the time of review.
A resident with chronic kidney disease and heart failure was not properly monitored for a physician-ordered 1500 ml fluid restriction, resulting in repeated overconsumption of fluids. Staff interviews revealed inconsistent and incomplete documentation and monitoring practices, with no comprehensive system to total fluid intake from all sources. The DON confirmed that these inconsistencies made it difficult to ensure compliance with the physician's order.
A resident with multiple chronic conditions and severe cognitive impairment had a Foley catheter re-inserted for urinary retention, but the care plan was not updated to reflect this change. Despite daily IDT meetings where care plans are reviewed for status changes, the oversight was not corrected, and staff acknowledged the care plan should have been revised.
Surveyors found expired stock medications, including Calcium with Vitamin D, Aspirin, and Iron, in a medication storage room. An RN unit manager acknowledged responsibility for checking for expired medications but was unsure of the frequency of checks. The DON confirmed that expired medications should not be left in medication rooms.
A resident with severe cognitive impairment and multiple medical conditions, who was fully dependent on staff for bathing, did not receive a scheduled shower for a two-week period as required by the care plan. Facility documentation and staff interviews confirmed the missed care, with no additional information provided regarding the lapse.
Two residents developed pressure injuries that were not comprehensively assessed or managed according to facility policy. One resident developed a deep tissue injury and a sacral ulcer without timely or complete wound assessments, and care plans were not individualized to address specific risk factors. Another resident's unstageable pressure injury was not fully assessed, with missing documentation of wound depth and bed, and the wound physician and RD were not promptly involved. These deficiencies reflect failures in assessment, documentation, and individualized care planning.
Two residents with cognitive and mobility impairments experienced multiple unwitnessed falls due to the facility's failure to conduct thorough root cause investigations and implement personalized fall prevention interventions. Generic measures such as ensuring call lights were within reach were inconsistently applied, and care plans were not updated to address specific risk factors like toileting needs, proper footwear, or visual impairments. Post-fall assessments lacked key details, and interventions such as fall mats and visual reminders were not tailored to individual needs or placed effectively, resulting in inadequate supervision and repeated accidents.
An LPN failed to perform hand hygiene at multiple critical points during wound care for a resident with complex medical needs, including after touching contaminated surfaces, changing gloves, and handling wound dressings. This was observed despite facility policy requiring hand hygiene before and after glove use and when moving between contaminated and clean tasks. The DON confirmed that proper hand hygiene was not maintained during the procedure.
A facility failed to notify the activated Medical Power of Attorney (MDPOA) of a resident about the discontinuation of rehabilitation services, as required for informed health care decisions. The Advance Beneficiary Notice (ABN) was incorrectly provided to the resident instead of the MDPOA, preventing the opportunity to appeal the decision. The Director of Rehabilitation and Director of Nursing acknowledged the oversight.
A resident with intact cognition and specific care preferences was not respected when a male CNA checked her brief for wetness, despite her care plan specifying no male CNAs for certain care. Staff interviews revealed a lack of awareness and communication about the resident's preferences, leading to a failure in honoring her choice.
A facility failed to implement a comprehensive care plan for enhanced barrier precautions (EBP) for a resident with multiple diagnoses, including Parkinson's and diabetes with a foot ulcer. The care plan required staff to wear a gown and gloves during wound care, but an LPN did not follow these precautions, as observed during a wound care session. Interviews with facility staff confirmed the care plan was not followed, potentially putting the resident and others at risk for infections.
A facility failed to follow its infection control program for a resident with wounds, as an LPN did not adhere to enhanced barrier precautions. The LPN entered the resident's room without sanitizing hands or wearing a gown, did not clean the overbed table before placing supplies, and failed to change gloves or wash hands at appropriate times during wound care. Interviews revealed a lack of adherence to infection control training and protocols, potentially risking infection spread.
The facility failed to ensure proper infection control practices, as a nurse used an alcohol wipe instead of a disinfectant wipe on a shared glucometer between residents, and a laundry aide handled clean linen without removing soiled PPE. These actions were against facility policies, potentially exposing residents to infections.
The facility failed to provide adequate pressure ulcer care for four residents, as their pressure injuries were not comprehensively assessed upon admission, and their air mattresses were not set according to their weight. This led to inconsistent and inadequate care for residents with pressure injuries.
A resident experienced a significant weight loss of 23 pounds or 10.7% in 8 days, which was not addressed by the dietician or reported to the physician. Despite daily weight monitoring and a care plan in place, the facility failed to take appropriate action to manage the resident's nutritional needs.
Two residents were administered insulin in public areas without privacy, contrary to facility policy. An LPN administered insulin to one resident in a hallway and checked another's blood sugar and administered insulin in a TV room, both in the presence of other residents. This issue had been previously raised in a Resident Council meeting.
Two residents with non-pressure wounds were not comprehensively assessed upon admission, leading to inadequate documentation and care. Initial assessments lacked depth measurements and accurate wound descriptions, with discrepancies in wound locations. Comprehensive assessments were delayed until the Wound Physician's evaluation.
A resident with hemiplegia and spastic hemiparesis was not consistently provided with a left hand splint as required by their care plan, leading to a deficiency in care. Despite the care plan's directive to apply the splint for 6-8 hours daily, it was documented as worn only 9 times over three months. Staff noted the resident's occasional refusal to wear the splint, but these instances were not properly documented or communicated to the occupational therapist or physician, contrary to facility policy.
A resident with Type 2 Diabetes Mellitus did not receive their prescribed Lantus insulin injections on three occasions due to RN-K's decision to hold the medication based on low blood sugar readings, without a physician's order. The facility's policy requires medications to be administered as ordered, and the DON confirmed that any concerns should be communicated to the physician. No documentation was found to support the decision to hold the insulin.
Failure to Complete PASARR and Notify State Authority After Significant Change in Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to complete required PASARR screenings and notify the state authority of significant changes in mental illness for a resident with a 30‑day PASARR exemption. The facility’s policy, revised 1/26, states that all applicants will be screened for serious mental disorders or intellectual disabilities per state Medicaid rules, that residents remaining beyond a 30‑day exemption must receive a Level 1 PASARR and be referred for Level 2 evaluation when indicated, and that any resident with newly evident or possible serious mental disorder or related condition will be referred to the state authority for a Level 2 resident review. The policy also assigns responsibility to the Social Services Director to track each resident’s PASARR status and make referrals. Despite this, a resident admitted with a PASARR dated 10/15/25 and a 30‑day exemption remained in the facility without a new Level 1 PASARR being completed before the exemption expired. Record review showed that the resident’s mental health status changed significantly after admission. A quarterly MDS dated 1/21/26 documented a BIMS score of 3, indicating severely impaired daily decision‑making skills, and a PHQ‑9 score of 13, indicating moderate depressive symptoms. The resident was diagnosed with Unspecified Mood Affective Disorder on 12/9/25 and Adjustment Disorder with Depressed Mood on 2/27/26, and was started on Paroxetine for anger and sexual inappropriateness on 1/8/26, with Depakote Sprinkles and PRN Ativan ordered on 3/27/26 for behaviors. Despite these new psychiatric diagnoses and psychotropic medication changes, the facility did not initiate a new PASARR process or notify the state authority of the significant change in mental illness. During interviews, the Social Services Director stated having nothing to do with processing PASARRs and not knowing who completes new Level 1 PASARRs when residents remain past 30 days or when new diagnoses and medications are added, and the DON confirmed that a new Level 1 PASARR had not been completed when the diagnoses and medications were initiated.
Failure to Enter Orders and Document Use of Cardiac Event Monitor
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for one resident who was readmitted from the hospital with a cardiac event monitor. The resident had multiple diagnoses including syncope, pulmonary emboli, COPD, type 2 diabetes, dementia, congestive heart failure, and venous insufficiency, and had recently been hospitalized for atrial flutter with rapid ventricular response. The hospital After Visit Summary specified that a [NAME] cardiac monitor (Body Guardian Mini plus) was placed on the resident’s left chest for continuous rhythm evaluation for 7–14 days, with the monitor hooked up prior to discharge. On readmission, facility documentation on the evening of 12/11 noted the monitor was intact, and a nurse practitioner note on the morning of 12/12 confirmed the monitor was in place and ordered to be maintained for 7–15 days from hospital discharge. Despite these instructions, facility staff did not enter a physician order for the [NAME] monitor into the resident’s record, and the monitor was not transcribed onto the MAR or treatment record. When the resident’s cardiovascular care plan was revised on 12/11 to add atrial flutter, staff did not add an intervention related to the [NAME] monitor or its required duration of use. Review of the 24-hour board from 12/11 through 12/14 showed only two entries referencing the monitor: one on the PM shift of 12/11 indicating the left chest body guardian monitor was on, and one on the PM shift of 12/14 instructing staff to check the monitor box at the desk. There was no documentation on multiple shifts that the monitor was in place and functioning, and no documentation at all about the monitor on 12/15, the day the resident was discharged. Interviews with staff further demonstrated a lack of consistent process and documentation regarding the [NAME] monitor. One LPN who worked on the resident’s unit on several of the relevant dates stated they were unsure how such a monitor should be documented and could not recall whether the resident had a heart monitor in place during that period. Another LPN stated they would normally ensure an order was placed so the monitor would appear on the MAR and be written on the 24-hour board, but was unsure about care plan inclusion. The ADON reported that such a monitor should be documented under an “other” tab, should have an MD order so placement could be checked each shift, and should be included in the care plan, but did not recall this specific resident’s monitor use. The surveyor concluded that from readmission until discharge, there was no MD order, no care plan intervention, and incomplete documentation that the [NAME] monitor was functioning and in place each shift as ordered.
Failure to Provide Accurate Pressure Injury Management and Implement Heel Offloading Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure injury care consistent with professional standards and its own policy for two residents with existing pressure injuries. For one resident with multiple comorbidities including COPD, diabetes, dementia, CHF, and venous insufficiency, the resident was admitted with an unstageable sacral pressure injury that was later assessed by the wound physician as a stage 3 pressure injury. After two separate hospitalizations and readmissions, facility nursing staff documented the sacral wound as a stage 2 pressure injury on both readmission skin assessments, despite prior documentation by the wound physician that the wound was stage 3 and later unstageable. The surveyor noted that a stage 3 pressure injury cannot be down-staged to stage 2, indicating that facility staff incorrectly staged the wound on both readmissions. In addition to incorrect staging, the same resident’s wound treatment orders were not updated in the medical record when the wound physician changed the strength of Dakin’s solution used for cleansing. On one visit, the wound physician changed the treatment from 1/2 strength to 1/4 strength Dakin’s, but facility staff continued to follow the old order and used 1/2 strength Dakin’s for several days. Later, the wound physician changed the treatment back from 1/4 strength to 1/2 strength Dakin’s, yet the facility’s MD orders were not updated, and staff continued to use 1/4 strength Dakin’s until the resident was again hospitalized. Interviews with an LPN and the DON confirmed that the unit manager was responsible for updating MD orders after wound rounds and that staff were expected to assess, stage, and obtain appropriate treatment orders for wounds, including using the wound physician to confirm staging when needed. The second resident involved in the deficiency had severe cognitive impairment, was dependent on staff for ADLs and bed mobility, and had an unstageable left heel pressure injury. The resident’s skin integrity care plan included interventions such as offloading the heels, assisting with repositioning, and ensuring heel boots were on while in bed. During an observation of wound care by the wound physician, the resident was in bed with only socks on, no heel boots in place, and the boots observed in the chair. The wound physician stated the resident’s heels needed to be kept off the mattress and discussed with the RN unit manager whether heel boots or a wedge cushion would be better, noting the need to keep the heels off the bed. Subsequent observations showed the resident again in bed without heel boots, with bare feet and a heel boot lying next to the resident while the heels rested on the mattress. Interviews with the RN unit manager and an LPN confirmed that the resident was known to kick off heel boots, that staff were not known to be reapproaching or increasing rounds to ensure the boots remained on, and that the resident required staff assistance due to resistance to care, despite being able to remove the devices intended to offload the heels. Overall, the facility did not follow its own pressure injury prevention and management policy, which required accurate staging, prompt assessment and treatment, and monitoring and modification of interventions. For one resident, this included incorrect staging on readmission and failure to update and follow wound physician treatment orders. For the other resident, this included failure to implement the care-planned intervention of heel boots while in bed to keep the heels off the mattress, despite clear instructions from the wound physician and knowledge that the resident removed the boots.
Failure to Provide Medically-Related Social Services for Resident With Ongoing Sexually Inappropriate Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services to help a resident attain or maintain the highest practicable physical, mental, and psychosocial well-being, despite ongoing sexually inappropriate behaviors and evolving mental health diagnoses. The resident was admitted with dementia and had a severely impaired BIMS score and a PHQ-9 indicating moderate depressive symptoms. Over several months, nursing staff, a psychiatric NP, and a psychologist repeatedly documented sexually inappropriate behaviors, including grabbing at staff, making sexual comments, exposing himself, and focusing conversations on obtaining access to women. These behaviors were described as chronic, inadequately controlled, and resistant to redirection, with poor impulse control, impaired judgment, and limited insight. The facility’s own policy required provision of medically-related social services, including mental and psychosocial counseling, individualized non-pharmacological approaches, and care planning to address identified needs. Despite multiple nursing and psychiatric notes describing ongoing sexual disinhibition and aggression, the facility did not consistently translate these observations into targeted behavioral monitoring or care plan revisions. The treatment administration records (TARs) for October through March documented no targeted behaviors, even though progress notes during those same months described frequent sexually inappropriate conduct and staff discomfort. An intervention of “cares in pairs” was added to the comprehensive care plan in October, but interviewed staff were unaware it was to be implemented, and it was not listed on the Kardex. Psychiatric providers repeatedly recommended close behavioral monitoring, staff redirection, safety precautions, and supervision, but these recommendations were not further assessed or incorporated into the resident’s care plan until after a resident-to-resident sexual incident occurred in the dining room. The facility also failed to complete timely assessments and coordination related to the resident’s mental health status and sexual behaviors. Although the resident’s diagnoses expanded to include an Unspecified Mood Affective Disorder and later an Adjustment Disorder with Depressed Mood, and psychotropic medications were initiated and adjusted, the facility did not initiate the PASARR process or notify the state authority of these significant changes in mental illness diagnoses and treatments. Additionally, no assessment of the resident’s capacity to consent to sexual activity was completed prior to the resident’s repeated sexually focused interactions and the eventual sexual incident with a peer, despite ongoing documentation of sexual behavior and the resident’s severely impaired decision-making skills. The Assessment of Resident Capacity to Consent to Sexual Activity was only completed after the incident, at which time the resident was found unable to answer the assessment questions. The Social Services Director reported discomfort with conducting such assessments, acknowledged not reviewing psychiatric notes for care plan revisions, and was unaware of their role in the PASARR process, further evidencing the lack of medically-related social services to address the resident’s identified needs. The deficiency culminated in an alleged sexual interaction between this resident and another resident during a meal in the dining room, where staff observed the peer’s hand moving in an up-and-down motion near the resident’s lap and the resident adjusting his pants and pushing his penis into his pants. The facility’s own misconduct incident summary noted that the resident had a history of sexually inappropriate behaviors toward female staff that had shifted focus to female residents. This incident occurred in a public area with other residents present, and it followed months of documented sexually inappropriate behaviors and professional recommendations for supervision and monitoring that had not been fully assessed or integrated into the resident’s care planning and social services interventions. The facility’s policies on Social Services and Resident Assessment-Coordination with PASARR required the Social Services Director to pursue medically-related social services, monitor residents’ psychosocial functioning, and track PASARR status and referrals. However, the Social Services Director stated they did not review psychiatric recommendations for care planning and did not participate in PASARR processing or know who completed new Level I PASARR screenings when mental health diagnoses and medications changed. This disconnect between policy and practice contributed to the failure to provide appropriate medically-related social services, behavioral monitoring, and assessment of capacity to consent, leading to the identified deficiency.
Failure to Follow Mechanically Soft Diet Order and Obtain Required Diet Waiver
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident on a mechanically soft diet received food consistent with the ordered diet. The resident had a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the left side and was documented as cognitively intact with a BIMS score of 13. The resident’s MDS and care plan reflected an order for a regular diet with mechanical soft texture, and the care plan included an intervention to provide setup and assistance at meals for this mechanically soft diet. During a noon meal observation, the surveyor saw the resident in bed with two unopened snack-size bags and one opened snack-size bag of Doritos tortilla chips on the overbed table, and a multipack box of Doritos on a table in the room. When questioned, the resident confirmed being on a mechanical soft diet due to having no teeth or dentures, and stated that staff bring Doritos and Pepsi and that the resident is happy as long as these are provided. The cook, when interviewed, verified via the meal ticket that the resident was on a mechanical soft diet. The Activity Director reported that activities staff receive a weekly printout of residents’ diets from the dietitian and that a dietary list is kept in the general store so staff know what residents can purchase. The Activity Director stated that the resident’s family brings in chips and says it is acceptable for the resident to have them, and that activities staff purchase and provide two bags of Doritos daily using the resident’s $3 per day allowance. The RD and SLP both stated that Doritos are not appropriate for a mechanically soft diet and indicated that residents who choose to eat items not allowed on their altered diet should have a signed diet waiver with documented risk/benefit discussion; however, no such waiver or risk/benefit documentation was found in the resident’s record at the time of the surveyor’s review. This sequence of events shows that the resident routinely received and consumed Doritos despite an active mechanical soft diet order and without the required documentation of non-compliance with the physician-ordered diet.
Failure to Monitor and Enforce Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to monitor and document a resident's fluid intake in accordance with a physician's order for a 1500 milliliter (ml) fluid restriction. The resident, who had a medical history of chronic kidney disease and congestive heart failure, was admitted with a care plan and physician's order specifying the fluid restriction. Despite these orders, documentation from both the Treatment Administration Record (TAR) and meal intake records showed that the resident consistently consumed fluids in excess of the prescribed limit on multiple days. Interviews with facility staff revealed inconsistencies and gaps in the monitoring process. The Registered Dietitian calculated the daily fluid amounts to be provided by nursing and dietary staff but did not monitor the actual amounts nursing provided. Nursing staff, including RNs and LPNs, documented fluids given during medication administration on the TAR and relied on nurse aides to report meal intake, but there was no comprehensive system to total the fluids from all sources. The Unit Manager acknowledged that he did not add up the total fluids from both medication administration and meals, and only reviewed the TAR, excluding meal intake documentation by nurse aides. The Director of Nursing confirmed that due to inconsistent and incomplete monitoring, it was difficult to determine if the resident's fluid intake adhered to the physician's order. The Medical Director noted that while the resident had a potential for fluid overload, the significance of exceeding the fluid restriction would depend on clinical symptoms or lab values, which were not reported as problematic in this case. The deficiency was attributed to the lack of a coordinated and thorough monitoring process to ensure compliance with the fluid restriction order.
Failure to Revise Care Plan After Catheter Re-Insertion
Penalty
Summary
A deficiency occurred when the facility failed to revise the care plan for a resident after a significant change in condition. The resident, who had diagnoses including Alzheimer's disease, dementia, type 2 diabetes mellitus, major depressive disorder, chronic kidney disease stage 3, and benign prostatic hyperplasia, was admitted on hospice care and initially had a Foley catheter in place. The care plan for the indwelling Foley catheter was resolved after the catheter was removed. However, following an episode of urinary retention, the resident's catheter was re-inserted, but the care plan was not updated or re-initiated to reflect this change. Surveyor observations and record reviews confirmed that the resident continued to have a catheter in place, as evidenced by direct observation and progress notes documenting the re-insertion. Interviews with facility staff, including the registered nurse unit manager and the director of nursing, revealed that care plans are typically reviewed during daily interdisciplinary team meetings, especially when a resident experiences a change in status. Despite this process, the care plan for the resident was not revised after the catheter was re-inserted, and staff acknowledged that this oversight should have been addressed at the time of the status change.
Expired Medications Found in Medication Storage Room
Penalty
Summary
Surveyors observed that the facility failed to ensure that drugs and biologicals in one of two medication storage rooms were not expired. During an inspection of the 2nd floor medication room (2-East), expired stock medications were found in the cabinet, including a bottle of Calcium with Vitamin D with an open date of 11/22 and an expiration date of 7/2025, two unopened bottles of Aspirin 325 mg with an expiration date of 6/2025, and three bottles of Iron 27 mg (one opened with an open date of 1/23/2025 and expiration date of 4/2025, and two unopened with expiration dates of 4/2025). These findings indicate that expired medications were present and accessible in the medication storage area. When interviewed, the registered nurse unit manager (RNUM) stated that they had checked the cabinets upon starting employment in July 2025 but must have missed the expired medications. The RNUM indicated that while anyone could check for expired medications, it was ultimately their responsibility to ensure the task was completed. The RNUM was unsure of the frequency of these checks but guessed they occurred monthly. The director of nursing (DON) confirmed that medication rooms should be checked often and that expired medications should not remain in the medication rooms.
Failure to Provide Scheduled Bathing for Dependent Resident
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including sepsis, Myasthenia, subdural hemorrhage, epilepsy, abnormal posture, and colostomy, was admitted to the facility and required total assistance with activities of daily living such as toileting, showering, dressing, and transfers. According to the resident's care plan and Minimum Data Set (MDS), showers were scheduled every Friday on the evening shift. Documentation and nursing notes revealed that the resident did not receive the scheduled shower on 1/31/25, resulting in a two-week period without a shower or bath, contrary to the established plan of care. The deficiency was confirmed through review of the resident's records and interviews with the RN Unit Manager and interim DON, both of whom acknowledged the missed shower and the extended period without bathing. No additional information or explanation for the missed care was provided in the report.
Failure to Provide Comprehensive Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide necessary care and treatment to prevent and heal pressure injuries for two residents, resulting in the development and inadequate management of pressure ulcers. One resident, who was admitted without open wounds but assessed as at risk for pressure injuries, developed a deep tissue injury to the left heel and a pressure injury to the sacrum during their stay. Comprehensive assessments were not completed when these wounds were discovered, and the care plan was not individualized or updated to reflect the resident's specific risk factors and needs. Documentation of wound assessments lacked essential details such as staging, wound bed description, and surrounding skin assessment. The care plan interventions were generic and did not address the resident's immobility and incontinence, which were identified as primary risk factors. The first comprehensive wound assessment was not performed until several days after the wounds were identified, and only after the wound physician evaluated the resident. Another resident developed an unstageable pressure injury to the right calf, but a comprehensive assessment was not performed at the time of discovery. Weekly wound measurements failed to include depth, and there was no documentation of the wound bed, making it impossible to determine if the wound was improving or declining. The wound was not assessed with all required components, such as stage, length, width, depth, and a complete description of the wound bed. The registered dietitian was not aware of the pressure injury when it was discovered, and the wound physician did not see the resident as indicated. Documentation and care planning for this resident also lacked specificity and completeness, with interventions not tailored to the resident's needs and incomplete wound monitoring. The facility's policy required comprehensive skin and wound assessments, individualized care planning, and regular monitoring for residents at risk of pressure injuries. However, these procedures were not consistently followed for the residents in question. The lack of timely and thorough assessments, incomplete documentation, and failure to individualize care plans contributed to the deficiencies identified by surveyors.
Failure to Provide Adequate Supervision and Personalized Fall Prevention
Penalty
Summary
The facility failed to ensure that two residents received adequate supervision and assistance devices to prevent accidents, specifically falls. Both residents experienced multiple unwitnessed falls, and the facility did not conduct thorough investigations to determine the root causes of each incident. For one resident, there were repeated falls over a period of time, with documentation showing confusion, impaired mobility, and medication side effects as risk factors. Despite these known risks, the facility did not consistently update or personalize care plans to address specific contributing factors such as toileting needs, proper footwear, or the placement and visibility of fall prevention signage. Interventions were often generic, such as ensuring the call light was within reach, but these were not always implemented effectively or tailored to the resident's individual needs, such as visual impairments or cognitive deficits. In several instances, the facility's post-fall assessments lacked critical information, including when the resident was last observed, when toileting care was last provided, staff statements, and whether the call light was accessible at the time of the fall. The documentation also failed to clarify the circumstances leading up to the falls, such as how the resident moved to the location where the fall occurred or whether assistive devices were used appropriately. For example, one resident was found on the bathroom floor without clear documentation of how they got there, and another was found on the floor with an unlocked wheelchair, but the investigation did not address why the wheelchair was not locked or whether staff had checked on the resident as required. The facility's interdisciplinary team meetings and care plan updates often occurred after multiple falls had already taken place, and interventions were sometimes implemented late or not evaluated for effectiveness. Visual aids intended to prevent falls were not placed in locations visible to the residents, and assistive devices such as fall mats were introduced without documented assessments of need. The lack of comprehensive root cause analysis and failure to personalize interventions contributed to repeated falls and demonstrated inadequate supervision and hazard mitigation for residents at risk.
Failure to Maintain Hand Hygiene During Wound Care
Penalty
Summary
During an observation of wound care for a resident with multiple complex medical conditions, including cerebral palsy, protein-calorie malnutrition, and a history of deep tissue injuries, a Licensed Practical Nurse (LPN) failed to maintain proper hand hygiene at several critical points. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was receiving wound care for a pressure injury on the right calf. The LPN was observed touching potentially contaminated surfaces, such as the garbage can and the resident's heel boots, and handling wound dressings and supplies without performing hand hygiene between dirty and clean tasks. The LPN also changed gloves without performing hand hygiene in between, contrary to facility policy and accepted standards of infection prevention. The facility's hand hygiene policy required staff to perform hand hygiene before and after glove use, after handling contaminated objects, and when moving from contaminated to clean body sites. Despite these requirements, the LPN did not perform hand hygiene after removing the old dressing, after cleansing the wound, after removing gloves, or after completing the wound care. The LPN acknowledged typically using hand sanitizer between glove changes but did not have any available during the observed procedure. The Director of Nursing confirmed that hand hygiene should have been performed throughout the wound care process.
Failure to Notify Activated Responsible Party of Therapy Discontinuation
Penalty
Summary
The facility failed to notify the family member and Activated Responsible Party (FM1) of a resident (R1) about the discontinuation of rehabilitation services, which is a requirement for making informed health care decisions. R1 was admitted to the facility with FM1 as the activated Medical Power of Attorney (MDPOA) due to R1's incapacity to make her own health care decisions, as documented by two physicians. Despite this, the facility provided the Advance Beneficiary Notice (ABN) regarding the end of rehabilitation services directly to R1, who was cognitively intact but not legally authorized to make such decisions, instead of FM1. The facility's policy mandates notifying the resident's representative of any changes requiring notification, which was not adhered to in this case. The Director of Rehabilitation confirmed that the ABN was signed by R1 rather than FM1, acknowledging the oversight. The Director of Nursing also stated that the expectation was for the ABN notice to be provided to FM1, given her status as R1's activated MDPOA. This failure to notify FM1 prevented her from having the opportunity to appeal the discontinuation of therapy services, which she believed could have benefited R1.
Failure to Honor Resident's Preference for Female Caregivers
Penalty
Summary
The facility failed to honor a resident's preference to not have male Certified Nursing Assistants (CNAs) provide certain types of care, as outlined in her care plan. The resident, who had intact cognition and was admitted with diagnoses of diabetes and chronic kidney disease stage four, had a care plan specifying that no male CNAs should perform peri care or bathing. However, on one occasion, a male CNA entered the resident's room twice during the night to check her brief for wetness, which the resident found unacceptable. The CNA did not perform peri care but checked the brief for wetness, which the resident perceived as a violation of her preference. Interviews with staff revealed a lack of awareness and communication regarding the resident's preferences. The Registered Nurse (RN) on duty was unaware of the resident's preference, and the Unit Manager, who was responsible for scheduling, acknowledged that the resident's son had informed them of the preference upon admission. The Director of Nursing (DON) confirmed that the care plan specified no male CNAs for bathing and peri care, but there was a misunderstanding about whether checking the brief constituted peri care. This incident highlights a breakdown in communication and adherence to the resident's care plan, leading to the failure to respect the resident's preferences.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement a comprehensive care plan for enhanced barrier precautions (EBP) for a resident with multiple diagnoses, including Parkinson's, diabetes with a foot ulcer, hypertension, and a cerebral vascular accident. The resident's care plan, initiated on 09/27/24, included a requirement for EBP due to wounds, specifying that staff should wear a gown and gloves during wound care. However, during an observation on 10/22/24, an LPN did not wash or sanitize hands before entering the resident's room, which had EBP signage posted. Additionally, the LPN did not wear a gown while performing wound care on the resident's left heel and buttock, contrary to the care plan and posted instructions. Interviews with facility staff, including the MDS Coordinator, Administrator, and Director of Nursing, confirmed that the care plan for EBP was not followed. The MDS Coordinator stated that EBP should have been utilized as per the care plan, and the Administrator and Director of Nursing acknowledged that care plans should be adhered to and modified as needed to meet residents' needs. The failure to implement the EBP care plan had the potential to put the resident and others at risk for infections.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding enhanced barrier precautions (EBP) for a resident with a sacral wound and a left heel wound. The facility's policy required that wound care be conducted in a manner to minimize infection risk, including setting up a clean field, using no-touch techniques, and wearing appropriate personal protective equipment (PPE). However, during an observation, an LPN did not wash or sanitize his hands before entering the resident's room, which had a sign indicating the need for EBP, including wearing a gown and gloves. The LPN did not wear a gown during the wound treatment, contrary to the facility's policy and the posted precautions. The LPN also failed to clean the overbed table before placing supplies on it and did not use a barrier, despite the table being cluttered with personal items. During the wound care process, the LPN did not change gloves or wash hands at appropriate times, such as after removing the old dressing and before applying new ointment and dressings. The LPN used the same gloved finger to apply ointment after cleaning the wound, which was against the recommended practice of using a Q-Tip. Additionally, the LPN placed soiled items, such as a dirty washcloth and old bandages, inappropriately on the bed and floor, rather than disposing of them in a garbage can. Interviews with the LPN and the Director of Nursing (DON) revealed a lack of adherence to the facility's infection control training and protocols. The LPN admitted to missing the EBP sign and not following the correct procedures, while the DON confirmed the expected practices, such as wearing gowns and gloves, cleaning surfaces, and proper disposal of waste. The DON also noted that the Santyl ointment should have been applied with a Q-Tip, not a gloved finger. Despite the training provided, the LPN's actions during the wound care process did not align with the facility's infection control policies, potentially putting residents at risk for infection spread.
Infection Control Deficiencies in Glucometer Use and Laundry Handling
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of communicable diseases and infections. A Registered Nurse (RN) was observed using an alcohol wipe instead of a disinfectant wipe to clean a shared glucometer between residents. This practice was contrary to the facility's policy and the manufacturer's instructions, which require the use of a validated disinfecting wipe to clean the glucometer between each patient. The RN admitted to using the glucometer on three residents without proper disinfection, potentially exposing them to blood-borne pathogens, although none of the affected residents had such pathogens. Additionally, the facility did not adhere to proper infection control procedures in the laundry department. A Laundry Aide was observed handling clean linen while still wearing a gown and gloves that had been used to handle soiled laundry. Despite being reminded by the Director of Housekeeping/Laundry to remove the soiled personal protective equipment (PPE) before handling clean items, the aide proceeded without doing so. This action was against the facility's policy, which mandates the separation of soiled and clean laundry and proper PPE usage to prevent cross-contamination.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received care consistent with professional standards of practice to promote healing. Specifically, four residents with pressure injuries were not comprehensively assessed upon admission, and their air mattresses were not set according to their weight. This deficiency was observed in residents R188, R62, R14, and R12, who had varying degrees of pressure injuries and required specific interventions to promote healing and prevent further deterioration of their conditions. Resident R188 was admitted with multiple pressure injuries, including Stage 3 pressure injuries on the sacrum and unstageable pressure injuries on the left heel and left toe. The initial assessments were inconsistent, with discrepancies in wound measurements and locations. Additionally, R188's air mattress was set at 360 pounds, significantly higher than the resident's actual weight of 172 pounds. This incorrect setting was not addressed until six days after admission, during which time the pressure injuries were not comprehensively assessed or documented. Residents R62, R14, and R12 also had pressure injuries and were observed with air mattresses set incorrectly according to their weights. R62's mattress was set between 240 and 280 pounds, while the resident weighed 190.5 pounds. R14's mattress was set at 320 pounds, despite the resident weighing 163.5 pounds. Similarly, R12's mattress was set at 180 pounds, while the resident weighed 114 pounds. In all cases, there was no documentation or assessment to justify the mattress settings differing from the residents' weights, leading to inadequate pressure ulcer care and prevention measures for these residents.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility did not ensure that a resident received the necessary services to assist with nutritional maintenance, resulting in a significant weight loss of 23 pounds or 10.7% in 8 days. The resident, who had diagnoses including Diabetes Type 2, Dysphasia, and Dementia, was on a tube feeding regimen that was adjusted to include a mechanical soft diet. Despite the significant weight loss, there was no notification to the resident's physician, and the dietician did not assess the new weight loss or request a reweigh. The last nutritional assessment was conducted on 3/21/24, and the resident's weight was stable at that time. The dietician acknowledged the significant weight loss but did not take appropriate action to address it. The facility's policy on weight monitoring defines a significant change in weight as a 5% change in one month, requiring physician notification and dietician consultation. However, the resident's care plan, which was last updated on 4/19/24, did not reflect any interventions for the significant weight loss that occurred afterward. The resident's weights were recorded daily, showing a consistent decline, but this was not addressed by the facility staff. The dietician suggested that the use of different types of scales might have contributed to the issue but did not take further steps to resolve it. The findings were shared with the facility's Administrator and Director of Nurses, but no additional information was provided to address the deficiency.
Lack of Privacy During Insulin Administration
Penalty
Summary
The facility failed to treat residents with dignity during the administration of insulin, as observed by surveyors. Two residents, identified as R33 and R55, were administered insulin in public areas without privacy. R33 received insulin in the hallway by the nurses' station, while R55 had their blood sugar checked and insulin administered in the TV room, both instances occurring in the presence of other residents. The facility's policy on insulin administration, which mandates explaining the procedure and providing privacy, was not followed by LPN-G. The issue of insulin being administered in public spaces had been previously raised in a Resident Council meeting, where residents expressed concerns about insulin being given in the dining room. Despite this, the practice continued, as evidenced by the surveyor's observations. The Director of Nursing acknowledged that LPN-G was aware that blood sugar checks and insulin administration should not occur in public spaces, yet the deficiency persisted.
Inadequate Wound Assessment on Admission
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for assessing non-pressure wounds. Two residents, identified as R188 and R190, were admitted with non-pressure injuries that were not comprehensively assessed upon admission. The facility's policy required a full body skin assessment by a licensed or registered nurse upon admission, but this was not adequately performed for these residents. Resident R188 was admitted with multiple diagnoses and had wounds on the dorsal aspect of the left foot and fifth metatarsal, as well as other areas. However, the initial assessments did not include comprehensive documentation of wound depth or characteristics. The wound on the left dorsal foot was not documented at all, and there were discrepancies in the documentation regarding the location of the wounds. It took six days after admission for a comprehensive assessment to be conducted by the Wound Physician. Similarly, Resident R190 was admitted with several non-pressure wounds, including a diabetic ulcer and venous ulcers. The initial documentation by the facility was inconsistent with the hospital's records, with errors in wound location and lack of depth measurements or tissue type descriptions. The facility's documentation was difficult to follow, and it was not until the Wound Physician's assessment that more accurate and detailed information was recorded. The facility's process for assessing and documenting wounds on admission was inadequate, leading to deficiencies in care.
Failure to Apply Splint for Resident with Limited Range of Motion
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decline. The resident, who has hemiplegia and spastic hemiparesis affecting the left side following a stroke, was supposed to have a left hand splint applied for 6-8 hours daily as per their care plan. However, the splint was not consistently applied, with documentation showing it was worn only 9 times from February to April 2024. Observations by the surveyor revealed that the resident was frequently seen without the splint during various times of the day. Interviews with nursing staff indicated that the resident sometimes refused to wear the splint, but there was no consistent documentation of these refusals or communication with the occupational therapist or physician about the resident's non-compliance. The occupational therapist was unaware of the resident's infrequent use of the splint and had not observed any decline in the resident's condition. The facility's policy required that refusals be documented and communicated to the physician or therapist, but this was not done. The Director of Nursing confirmed that staff should notify the doctor or therapist if a resident consistently refuses to wear a splint.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure the accurate administration of medications for a resident with Type 2 Diabetes Mellitus, identified as R15. The resident had a physician's order for a daily Lantus injection, a long-acting insulin, which was not administered on three separate occasions by RN-K. The facility's policy requires medications to be administered as ordered by the physician, yet RN-K did not follow the MD order on 4/10/24, 4/18/24, and 4/24/24. RN-K held the Lantus injections based on her judgment of the resident's blood sugar levels, which were recorded as low on those dates, without any documented physician's order to do so. During interviews, RN-K stated that she would hold the Lantus if the resident's blood sugar was too low, even without a physician's directive, and would notify the physician only if the resident was symptomatic. However, the Director of Nursing (DON)-B confirmed that the protocol requires following the MD order and notifying the physician if there are concerns about administering Lantus. The surveyor found no documentation of a physician's order to hold the Lantus on the specified dates, and the DON-B acknowledged that a nurse would need an order to hold the insulin. The deficiency was discussed with the Nursing Home Administrator and the DON, but no further information was provided at that time.
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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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