Congregational Home, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Brookfield, Wisconsin.
- Location
- 13900 W Burleigh Rd, Brookfield, Wisconsin 53005
- CMS Provider Number
- 525700
- Inspections on file
- 15
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Congregational Home, Inc. during CMS and state inspections, most recent first.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident was not assessed completely and in a timely manner upon admission and at the required periodic intervals, as mandated by regulations.
The facility did not encode and transmit a resident’s assessment data to the State within the required 7-day period following assessment, as identified through record review.
Two residents did not have their quarterly MDS assessments completed within the required timeframe. The sole full-time MDS Coordinator was unable to keep up with all assessments due to lack of assistance, prioritizing Medicare MDS assessments and leaving quarterly assessments delayed or incomplete. The issue was acknowledged by facility leadership.
A resident with significant medical needs and a high risk for falls was rolled away from a CNA during incontinence care, contrary to facility policy requiring residents to be rolled toward the caregiver. This action caused the resident to fall from the bed into the space between the bed and the wall. The incident occurred despite clear facility protocols and staff expectations for safe resident handling.
A facility failed to report an allegation of neglect to the State Survey Agency within the required timeframe. A resident and their spouse filed a grievance about a care concern, which was later deemed neglectful and abusive by the spouse. The facility's social worker received an email about the allegation during a holiday weekend but did not report it until after the weekend, violating the facility's policy on timely reporting of such incidents.
A resident with Multiple Sclerosis and spasticity did not consistently receive prescribed ROM exercises twice daily, as facility staff failed to document the completion of these exercises. The resident's care plan lacked measurable goals, and some CNAs were hesitant to perform the exercises. The facility's Director of Nursing and Nursing Care Manager acknowledged the lack of documentation and a comprehensive care plan.
A resident with severe cognitive impairment and multiple medical conditions experienced multiple falls due to inadequate supervision and improper use of a Broda chair. The facility failed to thoroughly investigate falls, update care plans promptly, and ensure interventions were consistently implemented, despite the resident's high fall risk.
A resident at high risk for pressure injuries was not provided with an individualized care plan or consistent wound assessments, leading to the development of a deep tissue injury. The facility failed to document refusals of care and did not update the care plan to address the new injury.
The facility failed to ensure food safety and sanitation standards were met. Staff members were observed not wearing required beard hair restraints and handling ready-to-eat food with contaminated gloves, affecting the quality of food service for residents.
A resident with a foley catheter and bed canes did not have an individualized comprehensive care plan addressing these needs. Despite facility policy requiring such plans, the resident's care plan lacked specific interventions. The nursing care manager and director of nursing confirmed the oversight.
A resident experienced two falls from their recliner, and the facility did not thoroughly investigate the falls or update the resident's care plan with new interventions to prevent future falls. The facility's Falls policy and procedure were not followed, and the resident's fall risk admission assessment was incomplete. The Director of Nursing acknowledged the lack of thorough investigation and care plan updates.
The facility failed to document attempts to use appropriate alternatives and did not complete necessary assessments and obtain informed consent before installing bed rails for two residents. The Director of Nursing and Nursing Care Manager confirmed the deficiencies.
A resident admitted on hospice care did not have a physician certification of terminal illness, and the facility failed to designate a liaison between the facility and the hospice provider. The resident expressed frustration about unmet needs, and the hospice binder lacked necessary documentation. Facility staff were unaware of the missing certification and hospice order, leading to ineffective communication and coordination of care.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Complete Timely Resident Assessments
Penalty
Summary
A deficiency was identified when the facility failed to assess a resident completely and in a timely manner upon admission and then periodically, at least every 12 months, as required. The report notes that the necessary comprehensive assessment was not conducted within the specified timeframes, which constitutes noncompliance with assessment regulations.
Failure to Timely Transmit Resident Assessment Data
Penalty
Summary
The facility failed to encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. This deficiency was identified based on a review of facility records, which showed that required assessment data were not submitted to the State in the specified timeframe. The report does not provide additional details about specific residents or their medical conditions at the time of the deficiency.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for two of twelve residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, quarterly MDS assessments must be completed at least every 92 days following the previous OBRA assessment, with the completion date no later than 14 days after the Assessment Reference Date (ARD). For one resident, the quarterly MDS assessment was completed 23 days after the required due date. For another resident, the quarterly MDS assessment was still in progress and not completed by the specified deadline. The MDS Coordinator reported being the only full-time staff member responsible for MDS assessments and stated an inability to keep up with all required assessments due to lack of assistance. The Coordinator indicated that priority was being given to Medicare MDS assessments, resulting in quarterly assessments being delayed. During the Coordinator's absence, a pool nurse was covering the role, and the facility was in the process of training another RN for the position. The issue of late and incomplete MDS assessments was acknowledged by the MDS Coordinator and discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Adequate Supervision During Incontinence Care Results in Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance during incontinence care for a resident with multiple medical conditions, including vascular dementia, chronic kidney disease, and a history of falls. The resident was assessed as being at high risk for falls and was dependent on staff for activities of daily living, mobility, and transfers. During the incident, the CNA rolled the resident away from themselves while the bed was positioned next to the wall, contrary to facility policy, which states that residents should be rolled toward the caregiver when only one staff member is assisting. As a result, the resident rolled off the bed and onto the floor, landing in the space between the bed and the wall. The resident did not sustain an injury from the fall. Interviews with multiple CNAs and nursing leadership confirmed that the expectation is to roll residents toward the caregiver during care when only one staff member is present. The CNA involved in the incident did not follow this protocol, and there was uncertainty about whether the bed was properly positioned or if the brakes were locked at the time of the incident. The facility's policy and staff interviews consistently indicated that the correct procedure was not followed, leading to the resident's fall.
Delayed Reporting of Neglect Allegation
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency within the required timeframe. A resident and their spouse filed a grievance with the facility's social worker regarding a care concern that occurred on a specific date. The grievance was investigated, and the results were communicated to the resident and their spouse. However, during the Thanksgiving holiday weekend, the spouse sent an email to the social worker, indicating that they believed the incident was neglectful and abusive. The facility did not report this allegation to the State Agency until after the holiday weekend, which was beyond the required reporting timeframe. The facility's policy mandates that allegations of abuse, neglect, exploitation, or mistreatment must be reported immediately, or within 24 hours if the events do not involve abuse or result in serious bodily injury. Despite this policy, the facility did not have a process in place to address potential abuse or neglect concerns during non-working hours, such as weekends or holidays. The social worker, who was responsible for receiving and acting on such reports, did not check emails during the holiday weekend, leading to a delay in reporting the allegation to the State Agency. The resident involved in the incident had a medical history that included Multiple Sclerosis, Demyelinating Disease of the Central Nervous System, and Spastic Hemiplegia. The resident's cognition was intact, and they were responsible for themselves. The delay in reporting the allegation of neglect was identified during a surveyor's investigation, which included interviews with the resident, their spouse, and facility staff. The facility's failure to report the allegation in a timely manner was a deficiency noted by the surveyor.
Failure to Ensure Consistent ROM Exercises for Resident with Spasticity
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to maintain or improve their condition. The resident, who has a diagnosis of Multiple Sclerosis with spasticity, reported to the surveyor that they do not always receive assistance from facility staff to complete their prescribed stretching and range of motion (ROM) exercises twice daily, as indicated in their Certified Nursing Assistant (CNA) Kardex. The facility staff did not document when these exercises were completed, and the resident's care plan lacked measurable goals and interventions related to their spasticity and ROM. The resident's medical records and interviews with facility staff revealed inconsistencies in the implementation of the prescribed ROM exercises. Although the resident's CNA Kardex included detailed instructions for morning and afternoon stretches, there was no documentation in the electronic medical record to confirm that these exercises were being performed. Interviews with CNAs and the Nursing Care Manager indicated that while some staff were aware of the exercise requirements, there was no formal documentation process in place to verify completion. Additionally, some CNAs expressed reluctance or fear in performing the exercises, which may have contributed to the inconsistency in care. The facility's Director of Nursing and Nursing Care Manager acknowledged the lack of documentation and the absence of a comprehensive care plan with measurable goals for the resident's ROM exercises. Despite the resident's ability to communicate their needs and report any lapses in care, the facility did not have a restorative program in place to ensure consistent implementation of the prescribed exercises. This deficiency highlights a gap in the facility's processes for monitoring and documenting the care provided to residents with specific therapeutic needs.
Inadequate Supervision and Care Plan Updates Lead to Multiple Falls
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of assistive devices to prevent falls for a resident with severe cognitive impairment and multiple medical conditions, including dementia, anxiety disorder, and epilepsy. The resident, who was non-ambulatory and required a Broda chair for safety, experienced multiple falls that were not thoroughly investigated. The facility's policy required comprehensive post-fall assessments and updates to the care plan, but these were not consistently followed. The resident's falls were often unwitnessed, and there was a lack of documentation regarding the last known activities of the resident or whether prior interventions were in place. The Broda chair, which was supposed to be slightly reclined to prevent sliding, was not always positioned correctly, contributing to the falls. Additionally, the care plan was not promptly updated with new interventions following each fall, and staff statements were frequently missing from post-fall reports. Despite the resident's high risk for falls, as indicated by a Morse fall scale score and a history of previous falls, the facility did not ensure that interventions were consistently implemented or that the care plan was revised in a timely manner. The interdisciplinary team did not adequately follow up on incidents, and there was a lack of communication and documentation regarding the resident's care and supervision needs.
Failure to Provide Comprehensive Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident at high risk for pressure injuries was comprehensively assessed and provided with an individualized care plan to promote healing, prevent infection, and prevent new pressure injuries. The resident, who was admitted with a femur fracture and chronic kidney disease, had a Braden score indicating high risk for pressure injuries. Despite this, the facility did not initiate a turning or repositioning schedule for the resident, who subsequently developed a suspected deep tissue injury to the right heel. The care plan was not updated to address this new injury, and weekly wound assessments were not consistently conducted as required by the facility's policy. Observations by the surveyor noted the resident sitting in a recliner chair with their feet resting directly against the footrest, which could contribute to pressure injury development. The resident's medical records showed consistent measurements of the deep tissue injury over several months, indicating a lack of progress in healing. The facility's Director of Nursing (DON) acknowledged that the unit manager responsible for the resident's care had been terminated for not performing their duties, including weekly wound assessments. Interviews with the DON revealed that the resident often refused repositioning and the use of offloading heel boots, but there was no documentation of these refusals or discussions of the risks versus benefits with the resident or their representative. The Nursing Home Administrator (NHA) and DON were unable to provide additional information or justification for the lack of a comprehensive care plan and consistent wound assessments for the resident.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, Cook-J and Server-L were observed multiple times without wearing beard hair restraints while preparing and handling food in the kitchen. Despite the facility's policy requiring hair restraints to prevent hair from contacting exposed food, both staff members were seen without the necessary beard hair restraints on several occasions. The Certified Dietary Manager (CDM) acknowledged the issue and mentioned that they were waiting for an order of beard restraints, substituting them with hair nets in the meantime. However, the expectation was for staff to always have hair and beards completely covered, which was not adhered to during the observations. Additionally, Server-K was observed handling ready-to-eat food with gloved hands after touching non-sanitized surfaces without changing gloves or washing hands. This occurred multiple times, including touching the counter, their pants, and a metal cart before handling food meant for residents. The facility's policy states that gloves should be changed between tasks with proper hand washing, but this was not followed. The CDM confirmed that the expectation was for gloves to be changed between tasks, but this was not practiced by Server-K during the surveyor's observations.
Lack of Comprehensive Care Plan for Resident
Penalty
Summary
The facility did not ensure that a resident had an individualized comprehensive plan of care. The resident, who has a foley catheter and uses bed canes, did not have a care plan with specific interventions to address these needs. The facility's policy requires the interdisciplinary team to develop and implement a person-centered comprehensive care plan based on the resident's medical, physical, mental, and psychosocial needs. However, the surveyor found that the resident's care plan did not include interventions for the foley catheter or bed canes, despite these being documented in the resident's baseline care plan. The resident was admitted with diagnoses including malignant neoplasm of the bladder, chronic kidney disease stage 3, anxiety disorder, and restlessness and agitation. The resident is cognitively intact and requires various levels of assistance for daily activities. During the survey, the nursing care manager and the director of nursing confirmed that there were no care plans in place for the resident's foley catheter and bed canes, acknowledging that such care plans should have been developed and implemented. No further information was provided as to why the care plans were missing.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility did not ensure the environment remained as free of accident hazards as possible for a resident reviewed for falls. The resident experienced two falls from their recliner on separate occasions. The falls were not thoroughly investigated, and the resident's plan of care was not updated to prevent future falls with person-centered interventions. The facility's Falls policy and procedure were not followed, as the resident's fall risk admission assessment did not determine and document the level of fall risk, and the Morse Fall Scale was not completed as required. The resident's care plan, initiated on admission, included several interventions to prevent falls, such as ensuring the call light was within reach, wearing appropriate footwear, and maintaining a safe environment. However, after the resident's falls, the care plan was not updated with new interventions. The incident notes for both falls lacked documentation on whether the call light was on at the time of the falls or if there was any device in the recliner. Additionally, there were no Interdisciplinary Team (IDT) meeting notes to review the falls. The Director of Nursing acknowledged that a thorough investigation was not completed for both falls and that there were no care plan updates as a result of each fall from the recliner. The facility did not ensure that the resident had updated interventions in place to prevent accidents after experiencing two falls from the recliner. The IDT met to review the falls and implemented a new intervention, but no additional information was provided as to why the facility did not ensure updated interventions after the falls.
Failure to Document Alternatives and Assessments for Bed Rails
Penalty
Summary
The facility failed to provide evidence that it attempted appropriate alternatives before installing bed rails for two residents, R59 and R1. For R59, there was no documentation of a physician's order or a care plan for the use of bed canes. Additionally, the facility did not document any attempts to use appropriate alternatives before installing the bed assist bars. R59, who is cognitively intact, confirmed using the repositioning bars to pull himself up in bed, but the necessary assessments and documentation were missing. For R1, the facility did not update the assessment quarterly to document the risks and benefits of bed rails, nor did it obtain informed consent before the installation of half bed rails. R1's comprehensive care plan and physician orders were outdated and did not reflect the current use of half side rails. The facility also failed to document any attempts to use appropriate alternatives before installing the bed assist bars for R1. R1, who has moderately impaired decision-making skills, confirmed using the half siderails to boost himself up in bed. The facility's policy requires a comprehensive assessment, informed consent, and attempts to use appropriate alternatives before installing bed assist bars. However, these steps were not followed for R59 and R1, leading to deficiencies in the care provided. The Director of Nursing and Nursing Care Manager confirmed the lack of necessary documentation and assessments for both residents.
Failure to Ensure Coordinated Hospice Services
Penalty
Summary
The facility failed to ensure coordinated hospice services for a resident (R59) who was admitted on hospice care. The resident did not have a physician certification of terminal illness, and the facility did not designate a specific individual from the interdisciplinary team to act as a liaison between the facility and the hospice provider. The facility's hospice services policy and procedure require a coordinated plan of care, including a physician order for hospice services and a designated liaison, which were not in place for R59. Additionally, the resident's current physician orders did not include an order for hospice services, and the hospice binder lacked the necessary physician certification of terminal illness. During the survey, the resident expressed frustration and agitation about unmet needs, such as a non-working razor and hearing aids. The surveyor found that the hospice binder contained outdated progress notes and lacked the physician certification of terminal illness. The facility staff, including the Licensed Practical Nurse (LPN) and Social Worker (SW), were unaware of the location of the hospice binder and had not communicated the resident's concerns to the hospice team. The Director of Nursing (DON) and Admissions Director (AD) were also unaware of the missing physician certification and hospice order. The surveyor's interviews with facility staff revealed a lack of communication and coordination between the facility and the hospice provider. The Hospice Social Worker (HSW) confirmed that the resident's concerns had not been communicated, and a new plan of care was needed. The facility had not designated a specific individual to act as a liaison, and the physician certification of terminal illness was not attached to the hospice comprehensive care plan upon the resident's admission. The facility's failure to ensure proper documentation and communication resulted in the resident's care concerns not being addressed effectively.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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