Edgerton Care Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Edgerton, Wisconsin.
- Location
- 313 Stoughton Rd, Edgerton, Wisconsin 53534
- CMS Provider Number
- 525241
- Inspections on file
- 33
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Edgerton Care Center, Inc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, high fall‑risk scores, and frequent incontinence experienced numerous unwitnessed and witnessed falls from bed, in the bathroom, and in peers’ rooms, including several falls related to toileting and one that resulted in multiple rib fractures. The facility’s fall policy required timely cause identification and ongoing evaluation, but incident reports often documented no root cause and no new interventions despite repeated similar events. The resident’s care plan listed various fall‑prevention approaches (e.g., low bed, scoop mattress, gripper socks, scheduled toileting, environmental adaptations), yet some entries were incomplete or not well matched to the resident’s severe cognitive deficits (such as a "call don’t fall" sign). Staff interviews and observations showed inconsistent knowledge and implementation of key interventions like Dycem in the wheelchair to prevent sliding, with some CNAs unaware of it and unable to locate it, while rehab staff stated it should be used and frequently replaced. Agency staff reported no specific fall‑prevention education, and the DON acknowledged that root cause analysis practices were unclear, the resident’s care plan had not yet been reviewed, and important interventions such as Dycem were not on the care plan, resulting in inadequate supervision and fall‑prevention for this high‑risk resident.
The facility failed to implement its own abuse/neglect and exploitation policies requiring screening and identity verification of employees and contracted temporary staff. An agency CNA used her mother’s identity and worked multiple AM, PM, and NOC shifts on different floors under a false name, after the staffing agency uploaded valid credentials for the mother to a shared portal. The NHA reported that the facility relied on the agency’s background checks and did not request photo ID from new agency staff at orientation or before their first shift, despite a contract clause stating the facility retained its own obligations to verify credentials. Police investigating a fraudulent food order discovered that the CNA working under the assumed name did not match the photo ID on file, and the CNA admitted she was using her mother’s identity to work. During this period, a resident filed a grievance alleging that a CNA left her wet and did not perform check-and-change per the care plan, and this grievance was attributed to the CNA known by the false name. The facility did not report a suspicion of a crime to the state survey agency and made no changes to its process for verifying the identity of new agency personnel after learning of the false identity.
The facility did not ensure proper disposal of garbage and refuse when surveyors observed both a recycling dumpster and a regular trash dumpster with lids left open, contrary to the facility’s sanitization policy requiring waste to be contained in dumpsters with closed lids. The Dietary Manager reported that wind or trash collection activities sometimes leave lids open, that trash and recycling are collected on scheduled days, and that kitchen staff empty trash daily and are expected to close dumpster lids if they find them open, but this did not consistently occur.
The facility failed to ensure timely assistance with ADLs and personal hygiene when residents used the call light system. The system relies on mobile devices carried by CNAs, but several devices were missing, and remaining devices were sometimes left at the nursing station and only checked intermittently. CNAs reported daily complaints from residents about long waits, and call light logs showed multiple cognitively intact residents waiting from nearly an hour to over two hours for care after activating their call lights. The NHA acknowledged prior technical issues with the new call light system, confirmed that each CNA should have a device, and was unaware that some devices were missing, noting that call lights could go unanswered if CNAs are not properly notified.
A resident with severe cognitive impairment and psychiatric diagnoses, known by staff to be verbally and physically aggressive toward staff and other residents, slapped another cognitively impaired resident when their wheelchairs became entangled in a hallway. A witnessing resident reported the incident to a CNA, who separated the residents and notified an LPN; the LPN performed only a brief visual check for injury, did not document the event, did not complete further assessment such as vital signs, and was unaware of any new interventions to prevent recurrence. The NHA acknowledged being told about the slap and that such incidents should be investigated, documented, and possibly reported to the state, but did not document the event, did not interview involved staff or other residents, and did not conduct a formal investigation, while other staff confirmed that no new behavioral or supervision interventions were added to care plans or CNA guides despite the aggressive resident’s ongoing history of combative behavior.
The facility failed to follow its abuse reporting and investigation policy in three separate incidents. In one case, two residents with severe cognitive impairment were involved in a resident-to-resident altercation where one allegedly slapped the other; staff separated the residents and informed the NHA, but there was no documentation, no complete assessment, no formal investigation, and no report to the state. In another case, an agency CNA was discovered by police to be working under a false identity, yet the NHA did not report this suspicion of a crime to the State Survey Agency and had no process in place to verify agency staff identification beyond relying on the staffing agency. In a third case, a CNA reported that another staff member yelled at a resident in pain, forced the resident out of bed against his stated wishes, and called him racist; although the facility investigated internally, the NHA did not report the allegation to the state, acknowledging she believed it sounded like abuse but chose not to report once she felt the reporting timeframe had passed.
A facility failed to follow its abuse policy after an alleged incident in which one resident with severe cognitive impairment, paranoid schizophrenia, and dementia reportedly slapped another resident. A CNA separated the residents and notified an LPN, who performed only a brief visual check for injury, did not take vital signs, and did not document the event. The NHA received verbal reports but conducted only an informal conversation with a resident witness, did not interview the reporting staff or other residents, did not document an investigation, and did not implement or communicate new interventions or care plan changes, despite the involved resident’s known history of verbal and physical aggression toward staff and other residents.
The facility failed to complete required annual performance evaluations for two CNAs as mandated by its own performance evaluation policy, which requires a review at the end of probation and at least annually thereafter. Record review showed that both CNAs, employed for multiple years, lacked a documented annual evaluation for the review year, and one CNA reported only receiving paperwork related to pay changes without feedback on job performance. The HR manager acknowledged that the evaluations had been started by a prior DON but not completed, and the NHA stated she expected staff to receive annual performance evaluations.
A resident with Parkinsonism had ordered Carbidopa-Levodopa 25-100 mg TID with specific timing instructions, including administration one hour prior to meals and within one hour of scheduled times, yet the MAR showed at least 32 doses given late, some by several hours. Facility policy required timely administration, documentation of medication errors, and reporting to the physician and resident, but the DON reported that staff likely were not completing medication error reports. The resident voiced concerns about not receiving medications on time and subsequently began self-administering medications, while the DON acknowledged ongoing issues with medication administration timing.
The facility did not provide required annual in‑service training and skills evaluations for two of four paid feeding assistants. Records showed that the Director of Rehabilitation and another feeding assistant each completed a state‑approved Feeding Assistant Program with skills review, but there was no documentation of any annual refresher training or competency review afterward. One feeding assistant confirmed there had been no additional training, and HR reported being unaware of the annual training and skills review requirement, while the NHA stated an expectation that such refresher training would occur per state regulations.
A resident who was cognitively intact and had prepaid for nursing care was discharged before the end of the paid period, but the facility failed to issue a refund within the required 30 days. The refund was delayed due to issues with the accounts payable system, and was not processed until more than two months after discharge, despite multiple follow-ups by the resident's family.
The facility did not ensure that residents received care and treatment according to professional standards, resulting in actual harm for two residents and potential harm for two others. A resident with neurogenic bowel and constipation was not properly assessed or monitored for fluid intake, output, or changes in mental status, leading to multiple hospitalizations for dehydration. Another resident with sudden gastrointestinal symptoms experienced a significant delay in being sent to the emergency department. Additionally, two residents with changes in condition were not properly assessed or monitored. These deficiencies occurred despite facility policies and state nursing practice requirements mandating systematic assessment, monitoring, and communication.
Staff failed to follow food safety protocols by not performing proper hand hygiene or changing gloves when handling food and touching surfaces, and by not maintaining clean kitchen equipment such as ovens, a steam kettle, and an ice machine. Additionally, food storage temperatures were not consistently monitored or documented, with instances of milk being stored above safe temperatures and incomplete refrigerator logs for resident food items.
The facility did not ensure immediate reporting of multiple alleged abuse and neglect incidents, including physical restraint, rough handling, threats by a family member, and residents left in soiled briefs or unattended. Staff failed to notify the NHA or DON within the required timeframe, and several incidents were treated as grievances rather than abuse allegations, resulting in a lack of timely reporting to authorities.
Multiple residents reported incidents of potential abuse or neglect, such as being left in soiled briefs, not being assisted to bed, or being physically restrained, but the facility only completed grievance forms without conducting thorough investigations or interviewing other staff and residents as required by policy.
Three residents with DNR status did not have signed DNR forms or physician orders in their medical records, despite facility policy requiring these documents. The admissions process failed to obtain and file the necessary advance directive paperwork, resulting in incomplete documentation for residents with moderate cognitive impairment and multiple medical conditions.
Two residents, both cognitively intact and with complex medical histories, voiced grievances regarding sleep disturbances and care concerns, but the facility failed to document, investigate, or resolve these issues. Staff interviews revealed inconsistent application of the grievance process, and the facility did not provide a grievance policy or log the complaints as required.
A resident with dementia and a history of combative behavior was physically restrained by an agency CNA and LPN, who held his hands down and prevented him from getting out of bed, contrary to his care plan. The resident sustained a skin tear and significant bruising, and reported to staff and police that he was hurt by the two staff members. The care plan requiring staff to stop care and reapproach was not followed, and the incident was not immediately reported to facility leadership.
A resident with severe cognitive and physical impairments was found in a power lift recliner with the remote control intentionally placed out of reach by staff, restricting the resident's movement. Staff reported this was done due to fall concerns, but there was no documented assessment or physician order for restraint use, and the facility's policy prohibits such actions for staff convenience or fall prevention.
Two residents did not receive adequate supervision or consistent implementation of accident prevention interventions. One resident with moderate cognitive impairment and nicotine dependence was observed improperly disposing of cigarette materials and not returning smoking items to staff, despite facility policy and staff awareness of these behaviors. Another resident with severe cognitive impairment and a history of multiple falls did not have care-planned fall prevention measures in place, such as Dycem, gripper socks, and floor mats, during multiple observations. Staff interviews confirmed inconsistent knowledge and application of required interventions, and facility leadership acknowledged lapses in monitoring and follow-through.
A resident with an indwelling urinary catheter did not have a current physician order specifying the catheter's size or balloon volume, nor a replacement schedule. Although the care plan and physician orders included instructions for catheter care and monitoring, they lacked an active order detailing the catheter specifications, which was confirmed by the DON during the survey.
A resident with multiple venous ulcers and chronic pain was observed experiencing significant pain during wound care, despite being premedicated with morphine as ordered. The LPN continued the dressing change while the resident cried out and showed visible signs of distress, without stopping or reassessing pain. Facility policy required staff to recognize and respond to pain, but these steps were not followed, resulting in the resident enduring pain throughout the procedure.
A resident reported that hot foods were frequently served cold, leading her to avoid certain menu items. A CNA confirmed that food trays sometimes sat out and became cold before being delivered. A test tray revealed that several food items, including eggs and sausage, were served below recommended temperatures, and milk was above the safe threshold. The Dietary Manager acknowledged that these temperatures did not meet facility standards.
A resident with a history of eye conditions was struck in the eye by an EZ stand strap during a transfer, causing discomfort. The facility failed to notify the physician immediately, contrary to policy, and the resident did not receive medical attention until three days later. Staff interviews revealed lapses in incident reporting and communication protocols.
A resident with multiple health conditions did not receive prescribed eye drops due to a backorder and staff confusion, leading to significant medication errors. The facility's protocol for medication administration was not followed, resulting in discrepancies in the MAR.
The facility failed to implement its abuse prevention policy by not removing a CNA from patient care after a resident accused the CNA of sexual abuse. The CNA continued to care for other residents independently, contrary to the facility's policy requiring removal from resident care during investigations.
The facility failed to report an allegation of abuse to the state agency and did not protect residents during the investigation. A resident alleged that a CNA touched her breasts, but the CNA continued to care for residents independently. Staff members were aware of the allegation but did not ensure proper reporting or removal of the CNA from resident care duties.
The facility failed to thoroughly investigate a sexual abuse allegation involving a resident. The investigation did not include all residents, particularly non-interviewable ones, and lacked a complete assessment of potential victims, violating the facility's policy and federal regulations.
The facility failed to reposition a resident with multiple diagnoses, including MELAS syndrome and hereditary spastic paraplegia, every two to four hours as required by their care plan. Documentation and interviews revealed multiple instances where repositioning was not performed or recorded, and the DON confirmed incomplete documentation despite staff education on the procedure.
The facility failed to adhere to professional standards for food service safety, including improper thermometer sanitization, storing personal food with resident food, undated and unmarked food, unclean equipment, and dented cans in circulation. These deficiencies potentially affected all 40 residents.
The facility failed to implement an effective infection control program, as evidenced by not initiating outbreak investigations and not testing or excluding symptomatic staff. A dietary aide, a driver, and a housekeeping staff member worked while symptomatic, and the facility followed internal guidance requiring at least three symptoms before testing or exclusion, contrary to CDC recommendations.
The facility failed to report alleged violations of abuse, neglect, and mistreatment involving four residents to the administrator and State Agency as required. Incidents included resident-to-resident altercations and staff roughness, none of which were properly reported or investigated.
The facility failed to ensure that residents received scheduled showers, with multiple residents missing several weeks of bathing. Staffing shortages and lack of formal policies contributed to the deficiency, impacting residents' personal hygiene and care.
A resident with moderate cognitive impairment and multiple medical conditions expressed concerns about an LPN who did not explain procedures or knock before entering her room. The LPN applied a Lidocaine patch without explanation, and the resident reported it was not applied correctly. The Nursing Home Administrator confirmed that staff are expected to announce themselves and explain procedures, which did not occur in this case.
The facility failed to ensure prompt resolution of grievances for a resident with multiple diagnoses. Despite concerns being raised by the resident's representatives about care issues, the facility did not follow its grievance policy, resulting in no feedback or resolution.
The facility failed to investigate and report two resident-to-resident incidents involving verbal abuse and intimidation. Despite residents reporting these incidents to staff, no formal investigations or self-reports were conducted, violating the facility's policies and procedures.
The facility failed to document whether two residents received or declined the influenza vaccine for the 2023 to 2024 season. Both residents' medical records lacked evidence of declination, consent, or administration of the vaccine until prompted by the surveyor's inquiry.
The facility failed to follow professional standards for pressure injury care and prevention for two residents. One resident did not receive timely treatment for an unstageable pressure injury, and another was observed without a pressure-reducing cushion, contrary to their care plan. The facility's policies on wound care and pressure injury prevention were not followed, leading to inadequate care.
The facility failed to provide adequate supervision and implement necessary interventions for two residents. One resident experienced multiple falls without appropriate follow-up, and another resident's behavior of putting non-food items in her mouth was not addressed in her care plan, leading to increased risk of harm.
Failure to Analyze and Implement Effective Fall-Prevention Measures for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a high fall‑risk resident with severe cognitive impairment and multiple comorbidities. The resident had diagnoses including paranoid schizophrenia, severe dementia with mood disturbance, unsteadiness on feet, hip pain post fall, muscle wasting, delusional disorder, PTSD, CKD, and Type 2 diabetes. The resident’s MDS showed a BIMS score of 2/15, indicating severe cognitive impairment, frequent bladder incontinence, wheelchair use, and a need for partial to maximum assistance with all ADLs. John Hopkins Fall Assessment scores consistently placed the resident at high fall risk. The facility’s fall policy required timely cause identification, ongoing assessment, and monitoring of interventions, but this was not consistently carried out. Over several months, the resident experienced numerous unwitnessed and witnessed falls in her room, bathroom, and peers’ rooms, including multiple falls from or near the bed and several falls related to toileting or incontinence. Incident reports repeatedly documented that no root cause was identified for many of these falls, and in several cases no new interventions were implemented despite recurrent patterns, such as falls while attempting to toilet, falls from bed, and sliding from the wheelchair. One fall while the resident was making her bed led to hospital evaluation and identification of multiple acute left rib fractures. The care plan contained numerous fall‑related approaches, including scheduled toileting, environmental adaptations, use of a low bed, scoop mattress, wheelchair with auto‑lock brakes, gripper socks, floor gripper strips, distraction and increased supervision with restlessness, and staff making the bed in the morning. However, the care plan also contained generic or incomplete elements (e.g., “Resident at risk for falling r/t ________” left blank) and interventions of questionable effectiveness for this resident’s cognition, such as a “call don’t fall” sign. Staff interviews and observations showed that care‑planned interventions were not consistently implemented or clearly communicated. On observation, the resident was seen in a wide low wheelchair, wearing gripper socks, but had slid down in the seat, and her bed was stripped and not made. CNAs gave differing descriptions of the resident’s fall interventions, with some citing items such as Dycem in the wheelchair and keeping the resident near the nurse’s station, while others were unaware of Dycem or stated the resident did not have it. When surveyed, staff could not locate Dycem in the resident’s room, despite therapy indicating the resident was supposed to have Dycem under the wheelchair cushion and that it needed weekly replacement due to the resident’s tendency to remove it. Agency staff reported no specific education on fall interventions and relied on the electronic care plan, which did not clearly include all needed interventions such as Dycem. The DON acknowledged uncertainty about when root cause analyses using the “5 Whys” were started, had not yet reviewed this resident’s care plan, and agreed that some interventions (e.g., a call‑don’t‑fall sign) were not appropriate for the resident’s cognitive status and that Dycem should have been on the care plan. Overall, the facility did not complete thorough root cause analyses for repeated falls and did not ensure that care‑planned fall interventions were appropriate, updated, and consistently in place, resulting in multiple falls, including one with major injury.
Failure to Implement Screening Procedures Allowed Agency CNA to Work Under False Identity
Penalty
Summary
The deficiency involves the facility’s failure to implement its written policies and procedures for screening staff, specifically agency CNAs, before they worked with residents. The facility had policies titled “Compliance with Reporting Allegations of Abuse/Neglect/Exploitation” and “Abuse, Neglect and Exploitation,” which required screening of potential employees, contracted temporary staff, students, volunteers, and consultants for histories of abuse, neglect, exploitation, or misappropriation of resident property. These policies also required background, reference, and credential checks, and documentation that such screenings occurred. However, the policies had no documented implementation, revision, or review dates, and the facility relied on the staffing agency’s processes without independently verifying the identity of agency staff upon arrival for orientation or their first shift. The events leading to the deficiency began when an agency CNA, later identified as CNA S, worked 12 shifts at the facility while posing as another CNA, identified as CNA T. The staffing agency had provided the facility with background and credential information for the person identified as CNA T, including a photocopy of an out-of-state driver’s license, and all credentials for that identity were verified and valid. The facility’s Nursing Home Administrator (NHA) stated that the agency obtained all required background information and uploaded it to a shared portal, and that the facility did not ask agency staff to provide identification at orientation because they had no reason to suspect the person was not who they claimed to be. The contract between the facility and the staffing agency specified that the agency would verify credentials, including photo identification, criminal background checks, and license verification, but also stated that this did not relieve the facility of its own statutory, regulatory, or contractual obligations to independently verify credentials and information. On one evening, local police investigated a fraudulent food order that had been delivered to the facility and identified the payer as the agency CNA known at the facility as CNA T. When police returned to the facility the next day to arrest this individual, they compared the woman presenting as CNA T with the photocopied driver’s license on file and noted that the woman did not match the photo. Further questioning revealed that the woman was actually CNA S, who admitted she was a travel CNA who had previously worked for the staffing agency but was suspended for attendance issues. She stated she created an account for her mother, CNA T, and had been working under her mother’s identity. During this period, she had worked multiple AM, PM, and NOC shifts on different floors under the false identity. The facility did not report this incident as a suspicion of a crime to the state survey agency, and the NHA acknowledged that no changes had been made to the process for verifying the identity of new agency personnel after the false-identity issue was discovered. During the surveyor’s review of facility records, it was also noted that a resident filed a grievance alleging that on one date a CNA left her wet and did not check and change her according to her plan of care. The facility’s investigation determined that the staff member involved was new, and the grievance was filed against the CNA identified as CNA T. Documentation of education provided to this CNA described her as new to the CNA occupation and a phenomenal worker who answered call lights and did not complain about tasks. This grievance occurred during the time period when the individual working under the name of CNA T was actually CNA S. The surveyor concluded that, due to the facility’s failure to implement its abuse/neglect and misappropriation policies and to confirm the proper identity of an agency CNA prior to work, an individual was able to work under a false identity for multiple shifts without proper screening by either the staffing agency or the facility, and that the facility did not change its screening practices even after learning of the false identity.
Improper Securing of Dumpster Lids and Refuse Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly by not ensuring that dumpster lids were shut and secured, potentially affecting all 54 residents. Facility policy on sanitization requires that garbage and refuse containers be in good condition, without leaks, and that waste be properly contained in dumpsters with lids. During observation on 3/26/26 at 10:25 AM, the surveyor noted one lid open on the recycling dumpster and one lid open on the regular trash dumpster. In an interview at 11:10 AM the same day, the Dietary Manager stated that sometimes the wind or the trash truck leaves the lids open, that regular trash is picked up three times a week and recycling once a week, and that kitchen staff are responsible for emptying trash daily and are expected to close dumpster lids if they see them open. No specific residents were individually identified in the report, and no additional clinical details or medical histories were provided regarding the residents who could be affected by this deficiency.
Prolonged Call Light Response Times Lead to Delayed ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who are unable to carry out activities of daily living received timely assistance to maintain grooming and personal hygiene, as evidenced by prolonged call light response times. The facility uses a call light system that sends alarms to mini mobile devices on each resident floor, with no central hub or visual/audible indicators outside resident rooms. Staff reported that there are supposed to be four mobile devices per floor for the scheduled CNAs, but some devices are missing, leaving only two on the third floor. One CNA stated that staff often leave a device in the central nursing area and only check it when they have time, and that many call lights are not answered timely or at all because CNAs do not hear the alarms and are too busy to check the devices. Another CNA reported receiving daily complaints from residents about long call light wait times and attributed these complaints to the lack of mobile devices. The call light log reviewed by the surveyor showed active and resolved alarms with the length of time taken to respond. Multiple cognitively intact residents reported extended waits for assistance with care after activating their call lights, and the call light log corroborated long response times. One resident reported waiting up to 45 minutes, with the log showing a wait of 1 hour and 32 minutes; another reported similar delays, and a third resident stated he had waited over an hour and a half, with the log showing a 1 hour and 34 minute wait. Another resident described waiting up to 4 hours and sometimes receiving no response at all, with the log showing a 1 hour and 10 minute wait. An additional resident stated she frequently waited over an hour, with documentation of a 2 hour and 36 minute delay, and another resident reported waiting over 2 hours, with the log showing a 50 minute wait. The Nursing Home Administrator acknowledged that the call light system is new, that it had experienced problems related to the facility’s wireless internet, and that each of the four CNAs per floor should have a device. The administrator was unaware that some mobile devices were missing and stated that call lights could possibly go unanswered if CNAs are not properly notified.
Failure to Investigate and Address Resident-to-Resident Abuse Involving Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident and to follow its own abuse, neglect, and exploitation policy after a resident-to-resident altercation. The facility’s policy requires prevention of abuse through identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, as well as immediate investigation and protection of residents when abuse is suspected or reported. In this case, a resident with a history of aggressive behaviors toward staff and other residents was known by staff to be verbally and physically aggressive, including prior incidents involving another resident. Despite this history, there was no evidence of effective interventions or monitoring to prevent further resident-to-resident conflict. The incident at issue occurred when two residents in wheelchairs became entangled in a hallway, and one resident slapped the other. A witnessing resident reported the event immediately to a CNA, who separated the residents and informed an LPN. The LPN assessed the slapped resident for red marks, reported the incident to the then-ADON and to the NHA, and informed the resident’s family member who arrived at that time. However, the LPN did not document the incident, did not obtain vital signs, and did not perform further assessment of either resident. The LPN was not aware of any new interventions being implemented, and nothing was placed on the 24-hour board or communicated in subsequent shift reports to guide staff in preventing recurrence. Multiple staff interviews confirmed that the aggressive resident had a pattern of combative and verbally aggressive behavior toward staff and residents, including a prior incident of hitting another resident. Staff also reported that no new interventions were added to CNA care guides or communicated after the altercation, despite the facility’s policy requiring identification, care planning, and monitoring of residents with behaviors that might lead to conflict. The NHA acknowledged being informed that a resident had slapped another resident and that this type of incident should be investigated, documented, and potentially reported to the state. Nonetheless, the NHA did not document the event, did not interview the involved staff or other residents, and did not conduct a formal investigation. The NHA relied on a later conversation with the witnessing resident, who described the contact as a light tap, and no further follow-up with the involved residents occurred. As a result, the facility did not ensure that the resident was free from abuse by another resident and did not carry out the required investigative and protective steps outlined in its abuse policy. The residents involved both had severe cognitive impairment as documented by BIMS scores of 02 and 00, and diagnoses including paranoid schizophrenia, unspecified dementia with mood disturbance, major depressive disorder, and Down syndrome. One resident’s care plan identified impaired decision-making related to psychiatric and cognitive diagnoses and directed staff to allow decision-making while ensuring the safety of the resident and others. Despite these known conditions and behavioral risks, there was no evidence that the facility updated care plans or implemented specific behavioral or supervision interventions following the altercation. The family member of the slapped resident reported not being contacted by the facility after the initial notification to explain what would be done to prevent future incidents and expressed concerns that the aggressive resident entered other residents’ rooms and took items. Overall, the facility’s inaction and lack of documentation, investigation, and care plan modification following a reported resident-to-resident slap constituted a failure to protect a resident from abuse and to follow established abuse prevention and investigation procedures.
Failure to Report and Investigate Alleged Abuse, Resident Altercation, and Staff Identity Fraud
Penalty
Summary
The deficiency involves the facility’s failure to immediately report and thoroughly investigate alleged abuse, neglect, exploitation, or mistreatment, and to notify the State Survey Agency and other required authorities as outlined in its own abuse policy. The facility’s written policy, dated 2025, requires an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation, including identifying and interviewing all involved persons and documenting the investigation. The policy also requires reporting all alleged violations to the administrator, state agency, adult protective services, and other required agencies within specified timeframes: within 2 hours if the allegation involves abuse or serious bodily injury, and within 24 hours if it does not. Despite these requirements, surveyors found three separate incidents involving three residents and one staff member where the facility did not follow its procedures for investigation and reporting. In the first incident, a resident with paranoid schizophrenia and severe dementia (R1) allegedly slapped another resident with severe dementia and Down syndrome (R5) on 2/16/26. A CNA (CNA D) was informed by another resident (R12) that R1 had slapped R5’s face; CNA D separated the residents and reported the incident to an LPN (LPN C). LPN C assessed R5 for red marks, reported the incident to the ADON, and informed a family member, but did not complete further assessment, did not document the incident, and did not conduct or initiate a formal investigation. The Nursing Home Administrator (NHA A) later acknowledged that she had been informed that R1 slapped R5, but there was no documentation, no interviews of the CNA or nurse who reported the incident, no follow-up with R1 and R5, and no broader inquiry into other residents’ safety. NHA A stated that a resident-to-resident altercation should be investigated and that this incident could have been potentially reportable to the state, but no investigation or report was completed. In the second incident, surveyors investigated a complaint that an agency CNA was working under a false name. The administrator reported that police came to the facility on 3/4/26 to arrest a CNA identified as CNA T for potential credit card fraud, and it was then discovered that the individual working as CNA T was actually another person (CNA S) using her mother’s identity to obtain work through the staffing agency. The administrator stated that the facility relied on the staffing agency’s hiring and background checks and did not request identification from agency staff upon orientation, and that no changes had been made to the process for verifying agency staff identity. When asked, the administrator acknowledged that she did not report this situation to the State Survey Agency, explaining that she believed it was an active police investigation related to credit card fraud rather than the false identity used to work at the facility. As of exit, the facility could not provide additional information explaining why it did not report the suspicion of a crime when it became aware that an agency CNA was working under false identification. In the third incident, a CNA (CNA Q) reported that another staff member forced a resident (R6) out of bed on 2/21/26 despite the resident’s expressed wish to remain in bed due to pain and to wait for morning medications. According to CNA Q, she informed another CNA that R6 did not want to get up, and that CNA then entered the room, yelled at R6, forced him out of bed, and called him racist. CNA Q stated she felt this was abusive and reported it to the nurse, who then reported it to the administrator. The facility conducted a thorough internal investigation into this allegation; however, the State Agency had no record of the incident being reported. In an interview, the administrator stated that she believed the allegation sounded like abuse and that she should have reported it to the state agency, but by the time she realized it should have been reported, the reporting timeframe had passed and she decided not to report it at all. Across all three examples, the facility did not ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment were immediately reported and investigated in accordance with its policy and state and federal requirements.
Failure to Investigate and Protect Residents After Alleged Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and respond to an alleged resident-to-resident altercation and to implement measures to prevent further incidents. Facility policy on Abuse, Neglect and Exploitation requires immediate investigation of any suspicion or report of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, determining whether abuse occurred, and documenting the investigation. The policy also requires actions to protect residents during and after an investigation, such as examining the alleged victim for injury, increasing supervision, providing emotional support, and revising the care plan. Despite these written procedures, the facility did not follow them after being informed that one resident allegedly slapped another resident’s face. The incident in question occurred when a CNA was informed by another resident that one resident had slapped a second resident across the face. The CNA did not witness the event but immediately separated the two residents and reported the incident to an LPN. The LPN reported that she assessed the alleged victim for red marks, separated the residents, and notified the ADON, who instructed her to keep the residents separated and to keep an eye on them. The LPN stated she did not complete any further assessment, such as vital signs, and did not document the incident. She also indicated she was not aware of any interventions put in place to prevent recurrence and that nothing was added to the 24-hour board or passed through in report on her next shift. Multiple CNAs reported that the resident alleged to have slapped others had a history of paranoia, delusions, and verbal and physical aggression toward staff and residents, including prior incidents of hitting another resident. The Nursing Home Administrator acknowledged that staff had verbally reported that a resident witnessed the alleged slap, but there was no documentation of the incident or any investigation. The Administrator stated she spoke with the resident witness, who described the contact as light tapping on the face and reported that the residents’ wheelchairs had become hung up, with no words exchanged. Based on this conversation, no further action was taken: the Administrator did not interview the CNA or LPN who reported the incident, did not interview other residents for safety concerns, did not conduct or document an investigation, and did not follow up with the two residents involved. The Administrator acknowledged that a resident-to-resident altercation should be investigated, that this incident could have been potentially reportable to the state, and that there should have been documentation, but none of these required steps occurred. As a result, the facility did not ensure that all alleged violations were thoroughly investigated or that steps were taken to protect residents and prevent further abuse or altercations. The resident alleged to have initiated the contact had significant cognitive impairment, with a BIMS score of 02 on a recent MDS Significant Change Assessment, and diagnoses including paranoid schizophrenia and severe unspecified dementia with mood disturbance. Staff interviews described this resident as verbally and physically aggressive with staff and residents, and as having a prior altercation with another resident. Despite these known behaviors and the facility’s own policy requiring identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, there was no evidence that the incident led to any new interventions, care plan revisions, or enhanced supervision. CNAs responsible for updating care guidance sheets confirmed that no new interventions were communicated or added following the incident. This pattern of inaction and lack of documentation demonstrates that the facility did not follow its abuse prohibition plan or investigative procedures in response to the alleged resident-to-resident abuse. The facility also failed to ensure the health and safety protections outlined in its policy during and after the alleged incident. There was no documented physical or psychosocial assessment of either resident beyond a brief visual check for red marks on the alleged victim. There was no evidence of increased supervision, emotional support, or counseling for the residents involved, and no revision of the care plan to address the behaviors and prevent recurrence. The Administrator confirmed that the matter remained at the level of informal conversation without formal follow-up. Consequently, the facility did not meet its own standards for immediate investigation, thorough documentation, and protective measures in response to an allegation of abuse, neglect, exploitation, or mistreatment.
Failure to Complete Required Annual Performance Evaluations for CNAs
Penalty
Summary
The deficiency involves the facility’s failure to complete required annual performance evaluations for certified nursing assistants (CNAs) in accordance with its own Performance Evaluations policy dated 9/2020, which states that each employee’s job performance shall be reviewed and evaluated at least annually following a 90‑day probationary evaluation. Record review showed that CNA U, hired on 1/28/15, did not have an annual performance evaluation completed for 2025, and CNA H, hired on 8/21/19, also did not have an annual performance evaluation completed for 2025. During interview, CNA H reported not recalling having a performance evaluation and stated they only received paperwork related to whether there was a raise, without information about job performance. The Human Resources Manager stated that the 2025 evaluations for CNA U and CNA H had been started by the prior DON but were not completed, and acknowledged that an annual evaluation is required. The Nursing Home Administrator stated she would expect staff to have an annual performance evaluation. No resident-specific medical histories or conditions are mentioned in the report, and the deficiency centers on the facility’s noncompliance with its policy and regulatory expectations for annual CNA performance reviews.
Repeated Late Administration of Parkinson’s Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to the administration of Carbidopa-Levodopa for a resident with Parkinsonism. Facility policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required that medication errors be documented, reported, and reviewed by the QAPI committee. The resident’s physician orders specified Carbidopa-Levodopa 25-100 mg to be given three times daily at set times, with special instructions that the medication be administered one hour prior to meals per the resident’s home routine and with an added notation to “PLEASE GIVE ON TIME!” Despite these orders and policy requirements, the medication was repeatedly administered outside the one-hour window on at least 32 occasions over a one-month period, including multiple doses that were more than two, three, five, and even six hours late. The surveyor’s review of the electronic medication administration record showed numerous late administrations across different ordered schedules, including doses scheduled for morning, midday, and afternoon that were consistently given late. During interview, the resident reported concerns about not receiving medications on time and stated that they now self-administer medications as done at home. In a separate interview, the DON, who had recently started in the role, stated that medications are expected to be given within one hour before or after the scheduled time and that, if a medication is late, staff are expected to complete a medication error report and notify the physician and the resident or responsible party. The DON also acknowledged awareness of medication administration times as an issue and indicated that she did not believe staff were completing medication error reports. No additional information was provided by the facility to refute or explain the pattern of late administrations for this resident’s Carbidopa-Levodopa.
Failure to Provide Required Annual Training and Skills Review for Feeding Assistants
Penalty
Summary
The facility failed to ensure that its Feeding Assistant Program included required annual training and skills review for two of four paid feeding assistants reviewed. Wisconsin state requirements for feeding assistants, aligned with 42 CFR 483.60(h), specify that feeding assistants must receive an annual in‑service on relevant feeding topics and must be evaluated yearly to document satisfactory skill performance and feeding competence. Surveyor review of the Director of Rehabilitation’s (DOR K) Feeding Assistant Training Program documents showed that DOR K completed the state‑approved program, including training and skills review, on 4/17/24, but there was no documentation of any annual training or skills evaluation after that date. Similarly, review of feeding assistant records for staff member [NAME] V showed successful completion of the state‑approved Feeding Assistant Program, including training and skills review, on 4/17/24, with no subsequent annual training or skills monitoring documented. During an interview, [NAME] V confirmed that there had been no additional training after completion of the initial Feeding Assistant Program. In a separate interview, the Human Resources representative (HR W) stated that no additional training had been provided to feeding assistants and acknowledged being unaware of the requirement for annual training and skills review. The Nursing Home Administrator (NHA A) stated that she would have expected refresher training to be completed in accordance with state regulations.
Delayed Refund of Prepaid Fees After Resident Discharge
Penalty
Summary
The facility failed to refund a discharged resident's prepaid fees within the 30-day timeframe specified in the admission packet. Record review showed that a resident, who was cognitively intact and had diagnoses including benign neoplasm of cerebral meninges and hemiplegia, prepaid for services but was discharged before the end of the paid period. Despite the facility's policy to issue refunds within 30 days of discharge, the refund request was not processed in a timely manner. Documentation revealed that the refund was not issued until 73 days past the required 30-day period. The delay was attributed to issues with the facility's new accounts payable software, which caused the refund request to be overlooked. The administrator confirmed that the refund was owed and acknowledged the delay, noting that the system did not catch the refund in a timely manner. The resident's family member reported having to contact the facility multiple times before the refund was finally issued.
Failure to Provide Care According to Professional Standards and Resident Needs
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for four residents, resulting in actual harm for two and potential for more than minimal harm for two others. For one resident with neurogenic bowel and constipation, the facility did not accurately assess or monitor for constipation, decreased fluid intake and output, or changes in mental status. This resident experienced multiple hospitalizations requiring IV fluids due to inadequate fluid intake, and the facility did not notify the primary care physician about the resident's insufficient fluid intake and significant increases in urine output. Documentation showed that the resident's fluid intake was consistently below the physician-ordered goal, with several days lacking any intake documentation, and no additional interventions were implemented despite repeated hospitalizations. Another resident experienced a sudden onset of four episodes of projectile coffee ground emesis, indicating possible gastrointestinal bleeding, but the facility delayed sending the resident to the emergency department by over two hours. For two additional residents, the facility did not complete focused assessments or continued monitoring after changes in condition, and changes in physical condition were not addressed as changes in condition by the facility. These failures were in direct violation of facility policies regarding bowel management, hydration, and the requirements of the Wisconsin Nurse Practice Act, which mandates systematic assessment, planning, intervention, and evaluation by nursing staff. The documentation reviewed revealed that nursing staff, including both RNs and LPNs, did not consistently perform or document required assessments, such as abdominal or bowel assessments, even when residents exhibited symptoms like lethargy, vomiting, or absence of bowel movements. There were also lapses in communication with physicians and responsible parties regarding significant changes in residents' conditions. Facility policies required regular monitoring, documentation, and reporting of bowel movements, fluid intake, and signs of dehydration, but these were not consistently followed, leading to repeated adverse events and hospitalizations for the affected residents.
Failure to Follow Food Safety and Sanitation Standards
Penalty
Summary
Facility staff failed to adhere to professional standards for food service safety, as evidenced by multiple observations of improper hand hygiene and glove use during food preparation and service. Staff were seen touching various surfaces in the kitchenette, such as refrigerator doors and toasters, and then handling ready-to-eat foods like bread without changing gloves or performing hand hygiene. Interviews with staff and the dietary manager confirmed knowledge of hand hygiene protocols, but also revealed inconsistent understanding and application of these practices during meal service. Surveyors also observed unsanitary conditions in the kitchen, including visible debris and buildup in two ovens, a white substance on the inside and outside of a steam kettle, and similar buildup on the outside of an ice machine. The dietary manager acknowledged that these items were not being cleaned according to facility policy, and cleaning logs did not include the ovens or steam kettle. Additionally, there was no log for cleaning the ice machine, and the frequency of cleaning was not being documented as required. Temperature monitoring of food storage was also deficient. A gallon of milk was left unrefrigerated on a cart and later found to be above the safe temperature threshold, leading to its disposal. Furthermore, a refrigerator used for resident food and drink on the second floor was not being monitored daily, with temperature logs showing multiple days without documentation. Staff interviews confirmed that kitchen staff were responsible for monitoring and recording temperatures, but this was not consistently done.
Failure to Timely Report Alleged Abuse, Neglect, and Mistreatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by both facility policy and federal regulations. Multiple incidents involving several residents were not reported to the appropriate authorities within the mandated two-hour timeframe. In one case, a resident with moderate cognitive impairment was found with a fresh skin tear and reported being physically restrained by staff. The CNA who discovered the injury left a voicemail for the Nursing Home Administrator (NHA) but did not make further attempts to reach the NHA or the Director of Nursing (DON), resulting in a delayed report of the abuse allegation. Other incidents included a resident with severe cognitive impairment reporting rough handling by nursing staff, which was mentioned to a social worker but not immediately reported to the NHA. Additionally, the facility was aware of a family member threatening to take away a resident's art supplies as a form of coercion, but this was not reported to the state agency or law enforcement. Several residents reported neglect, such as being left in soiled briefs or not being assisted to bed, and these were documented as grievances rather than abuse allegations, leading to a failure to report them as required. The facility's own policy defined immediate reporting as within two hours for allegations involving abuse or serious bodily injury, and required that all suspicions be reported to the administrator and other officials according to state law. Despite this, staff did not consistently follow the policy, and the NHA acknowledged that these incidents should have been reported and investigated as abuse allegations. The failure to report these events in a timely manner and to the appropriate authorities constituted a deficiency in the facility's abuse reporting procedures.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated as required by their own policy. Multiple incidents involving several residents were documented where the facility became aware of potential abuse or neglect, but only completed grievance forms without conducting comprehensive investigations. In each case, the facility did not interview other residents or staff members, nor did they take further steps to identify additional abuse or neglect, as outlined in their policy. Specific examples include residents who reported being left in soiled briefs overnight, not being assisted to bed, or having their call lights ignored. In one case, a resident was left in a wheelchair all night without being changed or assisted to bed, and in another, a resident was left in a wet brief after an enema and not cleaned up until the next morning. Another incident involved a resident who reported that a CNA waved a wet brief in his face after he complained about not being changed. In each of these cases, the facility's response was limited to completing a grievance form and providing minimal follow-up, without conducting a thorough investigation as required. Additionally, there was an incident where a resident was found with a skin tear and alleged that staff physically restrained him, but the facility did not immediately report the allegation, remove the accused staff from duty, or provide staff education regarding physical restraints. The facility's own administrator acknowledged that these incidents should have been reported and investigated more thoroughly, and that documentation was lacking. The facility also failed to assess or interview residents, take statements, conduct audits, or report certain incidents to law enforcement when required.
Failure to Maintain Advance Directives in Resident Medical Records
Penalty
Summary
The facility failed to ensure that copies of residents' advance directives, specifically Do Not Resuscitate (DNR) orders, were included in the medical records for three residents. According to facility policy, advance directives must be obtained and maintained in the resident's medical record, and the attending physician must be notified so that appropriate orders can be documented. However, for three residents with moderate cognitive impairment and multiple medical diagnoses, their electronic health records indicated DNR status, but there were no signed DNR forms or physician orders present in their files at the time of review. For one resident, the electronic health record displayed DNR status, but there was no signed Emergency Care DNR Order or physician's order in the medical record, despite the resident's wishes to be DNR. Similarly, another resident's record showed DNR status in the electronic health record, but lacked a signed DNR form and physician's order. The Nursing Home Administrator confirmed that no DNR paperwork was available for these residents at the time of the survey and that the admissions process had not ensured the collection of these documents. A third resident's record also indicated DNR status, and while there was a Facility Informed Consent and Provision of Resuscitation form signed by the responsible party and witnesses, it lacked a physician or advanced practitioner signature. There was also no physician order for DNR in the record. The admissions process, which should have included obtaining and verifying these documents, was not completed as required, resulting in the absence of necessary advance directive documentation in the residents' medical records.
Failure to Document, Investigate, and Resolve Resident Grievances
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal, and did not establish or follow a grievance policy to ensure prompt efforts to resolve grievances. Specifically, the facility did not document, investigate, or resolve grievances for two residents who were reviewed for grievances. The surveyor requested the facility's grievance policy, but none was provided. One resident, who was cognitively intact and had multiple medical diagnoses including heart failure and epilepsy, repeatedly voiced concerns about being unable to sleep due to a loud roommate. These concerns were documented in progress notes and by a nurse practitioner, but there was no evidence that the facility logged, investigated, or resolved the grievance. No follow-up actions, interviews, audits, or education were completed, and the grievance was not entered into the facility's grievance log. Another resident, also cognitively intact but with an activated healthcare power of attorney, and his family raised multiple grievances during care conferences, including concerns about safety, communication, and inaccurate tracking of input/output. These grievances were documented in care conference notes but were not investigated or logged by the facility. Interviews with staff revealed inconsistent understanding and application of the grievance process, with some staff indicating that such complaints should be considered grievances, while the Director of Social Services admitted not documenting every complaint as a grievance. The Nursing Home Administrator was unaware of at least one resident's grievance and expected staff to report such concerns.
Failure to Protect Resident from Physical Abuse by Agency Staff
Penalty
Summary
A resident with dementia, anxiety, depression, and a history of combative behavior during care required extensive assistance for daily activities. The resident's care plan specified that if he became combative, staff were to stop care, ensure his safety, leave the room, and reapproach later. On the night in question, an agency CNA and LPN failed to follow this care plan when the resident attempted to get out of bed. Instead, they physically restrained him by holding his hands down and preventing him from getting up, despite his resistance and requests to stop. The incident resulted in the resident sustaining a skin tear and significant bruising, including a thumbprint bruise, on his hands and forearm. The resident was found by another CNA, who observed fresh blood on his arm and bedding. The resident reported to multiple staff and a police officer that the two staff members had hurt him by grabbing his wrists and forcing him to stay in bed. Witness statements and documentation confirmed that the care plan was not followed, and the resident's physical injuries were consistent with his account of being restrained. Staff interviews and documentation revealed that the agency CNA and LPN did not stop care or reapproach as required by the care plan, and instead engaged in physical restraint, which is prohibited. The resident, who was on blood thinners and bruised easily, was left with visible injuries. The incident was not immediately reported to facility leadership as required, and the staff involved did not remove themselves from the facility until after the incident was discovered by incoming staff.
Resident Restrained by Withholding Recliner Remote
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and significant physical limitations, including Parkinsonism, lack of coordination, difficulty walking, and weakness, was observed in a power lift recliner with the remote control intentionally placed out of reach. The facility's policy defines a restraint as any device or equipment that restricts a resident's freedom of movement and cannot be easily removed by the resident. In this case, the remote was placed on the floor behind the recliner, making it inaccessible to the resident and thereby restricting his ability to adjust his position or get up independently. Staff interviews revealed that the remote was withheld due to concerns about the resident's history of falls, with an LPN stating this was the first time the remote was intentionally placed out of reach to prevent the resident from attempting to stand and potentially fall. The resident's care plan and assessment did not indicate the use of restraints, and there was no documented assessment by therapy regarding the safety of using the power recliner. The DON acknowledged that placing the remote out of reach could be considered a restraint, and the facility's policy prohibits the use of restraints for staff convenience or fall prevention without proper assessment and physician order.
Failure to Ensure Accident Prevention and Supervision
Penalty
Summary
The facility failed to ensure that two residents received adequate supervision and that accident prevention interventions were consistently implemented, resulting in deficiencies related to accident hazards and fall prevention. One resident with a history of schizoaffective disorder, moderate cognitive impairment, and nicotine dependence was observed not disposing of cigarette materials properly and not consistently returning smoking materials to staff after smoking. Despite the facility's policy requiring direct supervision or assessment for independent smoking, staff were aware that the resident often failed to return lighters and kept partially smoked cigarettes, yet did not consistently intervene or reassess the resident's ability to smoke independently. Observations confirmed that the resident disposed of cigarette butts in the facility driveway, flicked ashes onto the ground, and delayed returning the lighter to staff, contrary to facility policy and staff expectations. Another resident with severe cognitive impairment, a history of multiple falls, and several care-planned fall prevention interventions experienced eight falls over a two-month period. The resident's care plan included specific interventions such as Dycem in the wheelchair, gripper socks, gripper strips on the floor, a mat by the bed, and shoes kept in the wheelchair at bedside. However, surveyors observed that these interventions were not in place during multiple observations, and staff interviews revealed inconsistent knowledge and implementation of the care plan. The resident was seen without gripper socks or shoes, and the required fall prevention equipment was missing from the environment, despite the care plan directives. Interviews with staff and facility leadership confirmed that care-planned interventions were not reliably followed or monitored. The DON and NHA acknowledged that interventions were not always in place and that monitoring by supervisory staff was inconsistent, particularly during periods of staff transition or absence. The facility's failure to ensure that accident prevention and fall interventions were consistently implemented resulted in repeated falls and unsafe conditions for the residents involved.
Lack of Physician Order for Indwelling Catheter Specifications
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter did not have a current physician order specifying the catheter's size or balloon volume, nor a replacement schedule. The resident, who was admitted with diagnoses including heart failure, epilepsy, cardiac arrest history, urinary incontinence, and obstructive and reflux uropathy, was cognitively intact and had a care plan indicating the need for an indwelling catheter due to obstructive uropathy. The care plan and physician orders included instructions for catheter care, drainage monitoring, and bag changes, but lacked an active order detailing the catheter size and balloon volume. During the survey, the DON confirmed that there was no documentation in the care plan or physician orders specifying the required catheter size for the resident. Historical orders referenced catheter changes but did not provide ongoing, active orders for the catheter's specifications. Facility policy required documentation of clinical indications and ongoing assessment for catheter use, as well as a current list of physician orders for each resident, which was not met in this case.
Failure to Adequately Assess and Manage Pain During Wound Care
Penalty
Summary
Facility staff failed to adequately assess and manage pain for a resident with multiple venous ulcers during wound care. The resident, who had a history of peripheral vascular disease, chronic pain, and moderate cognitive impairment, was observed experiencing significant pain during dressing changes. Despite physician orders and care plan approaches specifying the use of prn morphine one hour prior to wound care, the resident was seen crying, yelling, and displaying visible signs of distress throughout the procedure. The LPN performing the wound care acknowledged administering morphine approximately 49 minutes before the treatment but continued the procedure despite the resident's ongoing pain and vocalizations. During the wound care, the LPN removed dressings and cleansed the wounds, which caused the resident to cry out, plead for the procedure to stop, and exhibit physical signs of pain such as wincing, clenching teeth, and shallow breathing. The LPN did not stop or reassess the resident's pain, instead encouraging deep breathing and continuing the treatment. Interviews with the LPN and other staff revealed that stopping wound care due to pain was not a common practice, and the LPN admitted she might have needed to stop the procedure in this instance. The resident's roommate also reported that the resident regularly screamed in pain during dressing changes. Facility policy required staff to recognize and respond to both verbal and non-verbal signs of pain, monitor the effectiveness of interventions, and modify approaches as necessary. Interviews with the DON and ADON confirmed that staff should premedicate as ordered and stop to reassess if a resident is in pain. However, these steps were not followed during the observed incident, resulting in the resident enduring significant pain throughout the wound care process.
Failure to Serve Food and Drink at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at safe and appetizing temperatures. One resident reported that hot foods, specifically scrambled eggs and vegetables, were often served cold, leading her to stop eating scrambled eggs. This resident stated that her food was cold approximately three times a week. A Certified Nursing Assistant (CNA) confirmed that trays sometimes sat out and became cold while staff attended to other resident needs, such as retrieving condiments, and acknowledged that this issue should have been reported. A test tray provided to the surveyor after meal service revealed that several food items, including scrambled eggs and sausage links, were served at temperatures below recommended levels, with the eggs at 115.3°F and sausage at 91.6°F. The milk was also above the safe temperature threshold at 45.4°F. The Dietary Manager confirmed that hot foods should be held at 165°F and milk at 41°F or lower, indicating that the served items did not meet these standards. The facility's policy required food temperatures to be tested and recorded prior to meal service to ensure safety and palatability, but this was not consistently achieved.
Failure to Notify Physician After Resident Injury
Penalty
Summary
The facility failed to immediately consult with a physician following an incident involving a resident, identified as R2, who was struck in the left eye by the strap of an EZ stand during a transfer. Despite the resident experiencing discomfort and requesting to go to the hospital, the physician was not notified until three days later during a scheduled eye appointment. The facility's policy requires immediate notification of the physician in such incidents, but this protocol was not followed. R2, who has a history of eye-related conditions including degeneration of the macula and dry eye syndrome, reported the incident to a nurse, who left a voicemail for the resident's daughter but did not notify the physician or complete an incident report. The resident's daughter later arranged for an eye appointment, where the resident was prescribed medication for ocular inflammation. The delay in medical consultation and treatment was contrary to the facility's policy, which mandates prompt notification of changes in a resident's condition. Interviews with facility staff, including the LPN and DON, revealed a lack of adherence to the incident reporting and notification procedures. The LPN admitted to not completing an incident report or notifying the physician, while the DON acknowledged that the expected procedures were not followed. The incident highlights a breakdown in communication and procedural adherence within the facility, resulting in a delay in appropriate medical intervention for the resident.
Medication Administration Errors Due to Backorder and Staff Confusion
Penalty
Summary
The facility failed to ensure the provision of pharmaceutical services for a resident, resulting in significant medication errors. The resident, who has Type 2 Diabetes Mellitus, Macular Degeneration, and Secondary Corneal Edema, did not receive prescribed Tobramycin-dexamethasone eye drops on multiple occasions due to a backorder issue. Additionally, the resident did not receive Maxitrol eye drops as scheduled because the medication was unavailable. The facility's Medication Pass Protocol requires checking medications against the MAR before administration and ensuring medications are administered as ordered, which was not followed in this case. The Director of Nursing (DON) confirmed that the Tobramycin-dexamethasone was never received by the facility, yet it was signed off as administered. Similarly, Maxitrol was marked as unavailable in the MAR, despite being signed off as given. The DON attributed these discrepancies to possible staff confusion and misplacement of medications. The facility did not conduct staff education regarding this incident, which was acknowledged by the DON during the surveyor's interview.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility did not implement its policy and procedure to prevent abuse, neglect, and mistreatment of residents, which had the potential to affect all 13 residents on the unit. Specifically, the facility failed to remove a CNA from patient care after an allegation of sexual abuse was made by a resident. The facility's policy, revised in April 2021, mandates that residents be protected from further harm during investigations. However, after the allegation was reported, the CNA continued to care for residents independently on a different floor, contrary to the policy that requires staff members accused of abuse to be removed from resident care until the investigation is complete. The incident involved a resident with diagnoses including anxiety disorder, unspecified injury of the head, memory loss, and muscle wasting. The resident accused the CNA of touching her breasts. Despite the allegation, the CNA was only moved to a different floor and continued to provide care to other residents. Interviews with the CNA, ADON, DON, and NHA revealed that there was a lack of clear communication and adherence to the facility's abuse prevention policy, resulting in the CNA continuing to work with residents after the allegation was made.
Failure to Report Alleged Abuse and Protect Residents During Investigation
Penalty
Summary
The facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse were reported to the state agency and other officials, and did not protect residents during the investigation. On 4/20/24, the facility became aware of an allegation by a resident that a CNA had touched her breasts. This allegation was not reported to the state agency and other officials, and the facility failed to protect other residents during the investigation. The facility's policy requires that any allegations of abuse be reported within the required timeframes and that residents be protected from further harm during investigations, which was not followed in this case. The resident involved was admitted with diagnoses including Anxiety Disorder, Unspecified Injury of Head, Other amnesia-Memory Loss, and Muscle wasting and atrophy. The CNA who was accused of the abuse was not immediately removed from resident care duties. Instead, he was moved to a different floor and continued to care for residents independently. The staff members involved, including the RN and ADON, were aware of the allegation but did not ensure that the accused CNA was removed from resident care or that the incident was reported to the state agency and other officials. Interviews with staff members revealed that there was confusion and a lack of clear communication regarding the appropriate actions to take following the allegation. The DON and NHA were informed of the allegation but did not ensure that the accused CNA was removed from all resident care duties. The facility's failure to report the allegation and protect residents during the investigation resulted in a deficiency in their abuse prevention and reporting protocols.
Incomplete Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an accusation of sexual abuse involving a resident (R2). The incident occurred on 4/20/24, when R2 alleged that a Certified Nursing Assistant (CNA) had touched her breast. The facility's policy mandates a thorough investigation of all abuse allegations, but the investigation in this case was incomplete. The Social Services (SS) staff member interviewed residents who were available but did not wake sleeping residents or check non-interviewable residents for signs of abuse. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that no skin checks were performed on non-interviewable residents, and the investigation did not include all necessary steps to ensure a comprehensive review of the allegation. The facility's policy on abuse prevention requires a thorough investigation and reporting of any allegations within the required timeframes. However, the investigation into R2's allegation was insufficient, as it did not include all residents, particularly those who were non-interviewable. The SS staff member gathered written statements from staff and interviewed some residents, but the investigation lacked a complete assessment of all potential victims. This incomplete investigation process failed to meet the facility's policy requirements and federal regulations for protecting residents from abuse.
Failure to Reposition Resident as Per Care Plan
Penalty
Summary
The facility failed to implement professional standards of practice to promote healing or prevent pressure injury development for one resident. The resident, who has diagnoses including MELAS syndrome, hereditary spastic paraplegia, and immobility syndrome, was care planned to be repositioned every two to four hours. However, facility documentation and interviews revealed that the resident was not being repositioned as required. The resident's Repositioning Tracker Flow Sheets showed multiple instances where repositioning was not documented or performed over several days. Interviews with the resident and multiple CNAs confirmed that the resident was not consistently repositioned every two hours as per the care plan. The resident indicated that there were nights when repositioning did not occur, although they could not recall the frequency. CNAs acknowledged the existence of paper documentation for repositioning but admitted that it was not always completed, and refusals were not consistently documented. The Director of Nursing (DON) confirmed that the resident was on a two-hour repositioning schedule and that it was expected to be documented. The DON also indicated that the repositioning tracker flow sheets were initiated in April and that staff had been educated on their use. Despite this, the DON observed incomplete documentation on the flow sheets, indicating a failure to adhere to the care plan and facility policies for repositioning and documentation.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety, potentially affecting all 40 residents. Cook Q was observed not allowing the thermometer to air dry after sanitizing before measuring resident food temperatures. Additionally, Cook L's personal lunch was stored in the facility's walk-in refrigerator with resident food. Undated and unmarked food was found in the unit refrigerator, and the facility's mixer was stored with food particles on it. The ice machine had a black and white buildup on the piping and the top inside of the ice cube storage compartment. Two dented cans were also found in circulation in the dry storage area. The facility's policies were not followed in several instances. The Quaternary Sanitizer Safety Data Sheet indicated that the thermometer should be allowed to air dry after sanitizing, which was not done by Cook Q. The facility's policy on food storage required all food to be labeled and dated, which was not adhered to as evidenced by the undated to-go container. The mixer, which had food particles on it, should have been cleaned after use the prior day. The ice machine policy required it to be cleaned as often as necessary to prevent buildup, which was not done. Lastly, the facility's policy on dented cans was not followed, as two dented cans were found in circulation despite the policy stating that dented cans should not be used if dented on a seam, top, or bottom.
Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with their own COVID-19 policy and CDC guidelines. The facility did not initiate an outbreak investigation when a dietary aide tested positive for COVID-19 after displaying symptoms. The dietary aide worked without a mask on the last day before reporting symptoms, and the facility did not follow outbreak protocols despite the aide working within 48 hours of a positive test result. Additionally, the facility did not test or exclude staff members who displayed symptoms consistent with COVID-19. A driver reported symptoms and a positive home test but was allowed to work for two hours while symptomatic. The facility did not test or exclude the driver immediately, citing internal guidance that required at least three symptoms before testing or exclusion. Similarly, a housekeeping staff member worked while symptomatic and was not tested or excluded until multiple symptoms developed, again following the same internal guidance. The facility's infection preventionist confirmed that the internal guidance from the previous nursing home administrator and director of nursing required staff to have at least three symptoms before being tested or excluded. This practice was not documented in any policy or CDC guidance. The facility was not in contingency or crisis staffing during these times, and the failure to follow CDC recommendations for testing healthcare personnel with even mild symptoms of COVID-19 was noted.
Failure to Report Alleged Violations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and the State Agency. This deficiency was observed in four out of five abuse investigations reviewed. Specifically, incidents involving residents R21, R31, R17, and R45 were not reported as required by the facility's policies and federal regulations. For instance, R21 experienced a resident-to-resident incident where a male resident entered her room, swore at her, and scared her. This incident was not reported to the Nursing Home Administrator (NHA) or the State Agency, and no investigation was conducted. Similarly, R31 reported being verbally humiliated by another resident during a bingo game, but this incident was also not reported or investigated properly. In another case, R17 had a thorough investigation into her missing property, but the initial report was not submitted to the State Agency. The facility's failure to submit the initial report was confirmed by the Facility Reported Incident (FRI) Intake Coordinator. Additionally, R45 reported that staff were rough when putting her into bed, but the facility did not report this allegation of abuse to the state agency within the required two-hour window. The NHA was informed of the incident but did not realize it was reportable until after consulting with the Director of Operations, by which time the reporting window had already passed. The facility's policies and procedures clearly state the need to protect residents from abuse, neglect, exploitation, or misappropriation of property and to report any allegations within the required timeframes. However, staff interviews revealed a lack of understanding and adherence to these policies. Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) indicated they would report incidents to their supervisors, but there was no consistent follow-through to ensure these reports reached the NHA or the State Agency. This lack of proper reporting and investigation compromised the safety and well-being of the residents involved.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) received the necessary services to maintain personal hygiene. Specifically, four residents (R17, R21, R31, and R23) were not receiving showers as per their schedules. For instance, R17 missed several weeks of bathing in January, February, and March, while R21 and R31 also had multiple weeks without documented showers. R23, who was admitted to the facility, did not receive a shower until seven weeks later, despite being dependent on staff for toileting and showering due to moderate cognitive impairment and other health issues. Interviews with staff, including CNAs and LPNs, revealed that staffing shortages were a significant factor contributing to the missed showers. CNAs reported that when they were unable to complete a shower, they would provide a bed bath instead and report the issue to the next shift or their supervising nurse. However, this did not always ensure that the residents received the necessary care. The Nursing Home Administrator (NHA) acknowledged the issue and stated that there was no formal policy and procedure for showers, relying instead on a shower sheet that outlined expectations. The surveyor's review of documentation and interviews with hospice staff further highlighted the deficiency. Hospice staff provided some showers to R23, but the facility was still responsible for basic care, which was not consistently provided. The NHA confirmed that there was no documentation of showers or refusals for R23 from the time of admission through December. This lack of consistent care and documentation indicates a failure to meet the residents' needs for personal hygiene and ADLs.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility did not ensure that each resident was treated with dignity and respect, as evidenced by the treatment of one resident (R347). R347, who has a moderate cognitive impairment and multiple medical conditions including acute respiratory disease, mitochondrial encephalomyopathy, mild vascular dementia, and epilepsy, expressed concerns about an LPN who did not explain procedures or knock before entering her room. The resident's husband, who often relays information due to her communication difficulties, also expressed these concerns. The facility's policy on resident rights, which includes treating residents with respect and dignity, was not followed in this instance. During an observation, the surveyor noted that the LPN entered R347's room without knocking or introducing himself, and applied a Lidocaine patch to her back without explaining the procedure. The resident later reported that the patch was not applied correctly and did not alleviate her pain. The Nursing Home Administrator confirmed that staff are expected to announce themselves and explain procedures to residents, which did not occur in this case.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility did not ensure prompt resolution of all grievances for one resident, identified as R47, who was admitted with diagnoses including hereditary spastic paraplegia, metabolic encephalopathy, disease of the spinal cord, and immobility syndrome. Resident Representatives N and O voiced multiple concerns regarding R47's care, including issues with his new bed, staff not repositioning him to offload pressure points, staff's lack of competence with his rare diagnosis, his room door not staying open, and the Power of Attorney not being contacted during changes in his condition. Despite these concerns being communicated to the Nursing Home Administrator (NHA) and Nurse Manager, there was no follow-up or feedback provided to the resident representatives, and the facility's grievance process was not utilized as required by their policy. Nurse Manager C and NHA A both acknowledged receiving the grievances from Resident Representatives N and O but admitted to not following the facility's grievance policy, which mandates documenting and addressing grievances promptly. The facility's policy requires the grievance official to review, investigate, and resolve grievances while keeping the resident and their representatives informed throughout the process. However, this procedure was not followed, resulting in the grievances not being documented or resolved, and the resident representatives not receiving any written or oral feedback regarding their concerns.
Failure to Investigate Resident-to-Resident Incidents
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for two residents. Resident 21 reported a resident-to-resident incident where a male resident entered her room, swore at her, and scared her. Despite this incident being reported to staff, no investigation or self-report was conducted. The Social Service Director and Nursing Home Administrator confirmed that they were unaware of the incident and acknowledged that it should have been investigated and reported. Resident 31 experienced a resident-to-resident incident during a bingo game where another resident made derogatory comments about her weight, causing her to feel humiliated and stressed. Although Resident 31 reported the incident to the administrator and activities staff, no formal investigation or self-report was conducted. The Social Service Director admitted to counseling Resident 31 but did not document or report the incident to the Nursing Home Administrator. Both incidents highlight a failure to follow the facility's policies and procedures regarding the investigation and reporting of abuse, neglect, exploitation, or mistreatment. The facility's policy mandates that all such incidents be thoroughly investigated and reported within the required time frames, which was not adhered to in these cases.
Failure to Document Influenza Vaccine Administration
Penalty
Summary
The facility failed to ensure that residents received education regarding the benefits and potential side effects of the influenza vaccine, and did not document whether the residents received or declined the immunization. This deficiency affected two residents, R37 and R41, who were reviewed for influenza immunizations. R37's medical record did not show evidence of a declination, consent, or administration for the 2023 to 2024 seasonal influenza vaccine. Similarly, R41's medical record lacked documentation of a declination, consent, or administration for the same vaccine season. R37 was admitted with diagnoses including asthma, malignant neoplasm of the prostate, type II diabetes, and heart failure. The surveyor found no documentation of the influenza vaccine being offered or administered to R37 until the surveyor's inquiry prompted the facility to obtain consent on 3/27/24. R41, admitted with diagnoses including malignant neoplasm of the uterus, malignant neoplasm of the ascending colon, type II diabetes, and antineoplastic chemotherapy, also had no documentation of the influenza vaccine being offered or administered until the surveyor's inquiry. The facility's policy required that the influenza vaccine be offered to residents between October 1st and March 31st, and that any refusal be documented, but this was not followed for R37 and R41.
Failure to Implement Pressure Injury Care and Prevention
Penalty
Summary
The facility failed to implement professional standards of practice to promote healing or prevent pressure injury development for two residents. Resident 16 was admitted with an unstageable pressure injury to the left lateral foot but did not receive treatment until seven days after admission. Additionally, there were no wound assessments or measurements documented from the time of admission until a week later. The facility's policies required immediate assessment and treatment, which were not followed, leading to a delay in care for Resident 16's pressure injury. Resident 47, who was at risk for pressure injury development, was observed sitting in a recliner without a pressure-reducing cushion. Despite the care plan indicating the need for offloading and repositioning every two hours, the resident was found without the necessary support to prevent pressure injuries. Furthermore, the resident's skin condition was not reassessed upon return from a hospital stay, and inappropriate materials such as fleece blankets were used, which could inhibit healing. The facility's policies on wound care and pressure injury prevention were not adhered to, resulting in inadequate care for both residents. The lack of timely treatment, proper documentation, and appropriate preventive measures contributed to the deficiencies observed by the surveyors. These actions and inactions highlight significant lapses in the facility's adherence to established care protocols for pressure injury management and prevention.
Inadequate Supervision and Failure to Implement Interventions
Penalty
Summary
The facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents. Resident R23 experienced four falls from the time of admission, and the facility failed to identify the root cause or implement interventions to prevent future falls. The falls occurred on 12/12/23, 12/16/23, 1/4/24, and 1/28/24, with no interventions entered into the care plan for these incidents. The facility's policy requires identifying possible causes within 24 hours of a fall and implementing pertinent interventions, which was not followed in R23's case. The fall reports for R23 were incomplete, lacking details such as pain observation, body observation, neurological check, mental status, possible contributing factors, and interventions. Interviews with the Nurse Manager confirmed that interventions were not put in place as required by the facility's policy. Resident R1, who has a history of putting non-food items in her mouth, did not have this behavior addressed in her comprehensive care plan. Despite incidents on 2/7/24 and 3/17/24 where R1 was found eating crayons and attempting to put puzzle pieces in her mouth, the care plan did not include interventions or goals related to this behavior. Observations on 3/25/24 showed R1 unsupervised in the day room near an unfinished puzzle, which posed a risk given her known behavior. Interviews with the Activity Director and an LPN confirmed that R1's care plan should have included interventions and goals related to her behavior of placing non-food items in her mouth. The facility's failure to follow its policies and procedures for fall prevention and behavior management resulted in inadequate supervision and increased risk of harm to residents R23 and R1. The lack of timely and appropriate interventions for R23's falls and the absence of a care plan addressing R1's behavior of putting non-food items in her mouth highlight significant deficiencies in the facility's care practices.
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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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