Elroy Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Elroy, Wisconsin.
- Location
- 307 Royall Ave, Elroy, Wisconsin 53929
- CMS Provider Number
- 525452
- Inspections on file
- 25
- Latest survey
- July 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Elroy Health Services during CMS and state inspections, most recent first.
A resident with dementia and a history of fractures fell and complained of pain to the right wrist and hip. Although a PA ordered STAT x-rays, the imaging was not completed as ordered, and the provider was not notified of the delay or the resident's worsening pain. The resident exhibited significant pain and changes in condition overnight, but was only sent to the ER the next morning, where multiple fractures were diagnosed. Staff interviews confirmed that required notifications and timely actions were not taken.
A resident with severe cognitive impairment and a history of falls was not provided with an environment free from accident hazards due to the facility's failure to incorporate family-provided information about her routines and preferences into her care plan or Kardex. Staff were unaware of key details such as her preference to sleep in a recliner in street clothes, and relied on education as a fall prevention measure despite her inability to follow instructions. The resident's behavior of disabling her own alarm was not addressed in her care plan, and the alarm was not functioning at the time of an unwitnessed fall that resulted in a hip fracture.
A resident with Alzheimer's disease was prescribed Olanzapine, an antipsychotic, without an appropriate clinical indication or documentation that non-pharmacological interventions were attempted or contraindicated. The medication was ordered for behaviors common in Alzheimer's, such as wandering and lack of safety awareness, which do not alone justify antipsychotic use according to facility policy.
The facility failed to provide adequate care to prevent and treat pressure injuries for two residents. One resident developed two stage 3 pressure injuries due to improper repositioning and treatment application, while another resident's pressure injury deteriorated due to lack of proper assessment and care. Observations revealed multiple layers between residents and air mattresses, and staff failed to document repositioning and incontinence care consistently.
The facility failed to provide adequate nursing staff, leading to long wait times for resident assistance and unmet care needs. Staffing levels were based on census rather than resident acuity, resulting in insufficient care, particularly on weekends. Residents reported delays in call light responses and meal service, while staff confirmed they were unable to complete all care tasks due to low staffing.
The facility did not maintain a sanitary environment for food service, affecting all residents. A dietary aide was observed without a beard restraint, garbage cans near the food prep area lacked lids, and a spill was found in the walk-in fridge. The Dietary Manager and Nursing Home Administrator acknowledged these issues.
The facility failed to maintain an effective infection prevention and control program during a COVID outbreak, with staff unaware of the outbreak and not adhering to mask-wearing protocols. The outbreak was prematurely declared resolved, and staff surveillance was incomplete, leading to staff returning to work too early after illness. These deficiencies potentially affected all 68 residents.
The facility failed to maintain a safe and comfortable environment, as the dining room was observed to be significantly cold, with temperatures recorded at 56.8 degrees Fahrenheit. Residents, including those with cognitive impairments, were seen wearing jackets or blankets to stay warm. Despite being aware of the issue from a Resident Council meeting, the facility had not implemented effective measures to resolve the problem, and staff confirmed the cold conditions.
The facility failed to provide an ongoing program to support resident choice of activities, as observed in four residents on D Hallway who were not offered or did not participate in meaningful activities. Despite documented preferences for activities, many days lacked any participation documentation. Staff interviews revealed issues such as understaffing and a lack of activities tailored for residents with dementia, contributing to the deficiency.
A resident was observed wearing only a hospital gown in the dining room, expressing discomfort and a lack of clothing options. Despite being cognitively intact, the resident had no access to his clothes, which were in his assisted living apartment, and had not been offered alternative clothing by the facility staff. The social worker acknowledged the issue and arranged for the resident's clothes to be brought, but only after the surveyor's inquiry were alternative clothes offered.
Two residents in a LTC facility expressed dissatisfaction with receiving scrambled eggs daily, despite communicating their preferences to the kitchen. Both residents, who are cognitively intact, had meal tickets that did not reflect their dislike for scrambled eggs. The facility's process for updating dietary preferences was not effectively implemented, leading to a deficiency in promoting resident self-determination.
A facility failed to report a resident-to-resident verbal abuse incident within the required timeframe. A resident with a history of verbal aggression caused another resident to cry, but the incident was not reported to the state agency. Despite staff acknowledging the behavior as abuse, the DON and NHA did not consider it reportable, leading to a violation of the facility's policy.
A facility failed to investigate an incident of resident-to-resident verbal abuse when a resident changed the TV channel in a shared space, leading to a verbal altercation with another resident who became visibly upset. Despite staff witnessing the incident and considering it verbal abuse, the facility did not conduct a formal investigation or follow its policy on abuse allegations.
A facility failed to develop a comprehensive care plan for a resident with schizoaffective disorder and behavioral symptoms. Despite the resident's cognitive intactness and documented behaviors, the care plan lacked objectives and interventions for psychosocial well-being. Staff interviews revealed attempts to manage behaviors verbally, but no specific interventions were documented. The DON acknowledged the absence of a care plan addressing the resident's behaviors.
A resident with dementia exhibited aggressive behaviors, but the facility failed to develop an individualized care plan addressing these behaviors. Staff reported that the resident often refused care and medications, and interventions were not documented. The Director of Nursing acknowledged the need for a care plan, but it was not implemented, leading to inadequate care for the resident.
A resident's COVID-19 status was inappropriately disclosed by a CNA in front of others, violating privacy rights. Additionally, the Social Services Director publicly reprimanded the resident for not following smoking protocols, causing discomfort and fear. These actions breached the facility's policies on resident rights and privacy.
A resident with a cervical disc disorder requiring assistance with ADLs did not receive showering or bathing services for 21 days during a COVID quarantine. Despite being scheduled for weekly showers, the facility failed to provide these services due to staffing shortages. The resident reported not receiving a shower or bath for over two weeks, and the facility's documentation confirmed the lack of services. The issue was not addressed until a complaint investigation began.
A resident with a history of falls and poor safety awareness experienced an unwitnessed fall. The facility failed to conduct a timely post-fall assessment as per their guidelines. The nurse on duty did not assess the resident until the next day, and the physician was informed over 24 hours later. This delay in assessment and reporting led to a deficiency in the quality of care provided.
A resident with multiple pressure ulcers did not receive wound care according to physician orders. The RN applied medi honey instead of the prescribed treatment and used paper towels for cleansing, which was inappropriate. The facility was out of the required calcium alginate, and the RN was terminated after this incident.
The facility failed to ensure a safe and homelike environment, as several residents reported non-functional sinks and a lack of hot water for weeks. Observations confirmed musty odors and inadequate water temperatures. Staff acknowledged the ongoing issues, and maintenance efforts had not resolved the problems.
The facility failed to provide showers to residents due to a lack of hot water, affecting their personal hygiene. Residents reported missing showers, and documentation showed they were not offered showers on specific dates. Staff confirmed the issue, with attempts to use cold water or transport hot water from other areas. The Director of Maintenance struggled to resolve the hot water system issues, impacting residents' ability to have hot showers.
A resident with moderate cognitive impairment was found holding a medication cup with pills without staff supervision. The facility did not complete a self-administration assessment or obtain a physician order for the resident to self-administer medications. The RN admitted to leaving the medications with the resident, contrary to facility policy requiring an assessment and prescriber's order.
A resident with a cognitive communication deficit reported verbal abuse by CNAs, involving yelling and swearing, through the grievance process. Despite facility policy requiring immediate reporting of such allegations, the Nursing Home Administrator did not report the incident to the state agency within the required timeframe.
A resident with a cognitive communication deficit reported verbal abuse by CNAs, including yelling and swearing. Despite the resident's intact cognition, the facility did not conduct a thorough investigation, failing to interview involved parties or remove staff from working with the resident.
The facility failed to maintain safe water temperatures, resulting in excessively hot water in some resident bathrooms. Residents reported concerns, and a surveyor confirmed unsafe temperatures. The Director of Maintenance acknowledged ongoing issues with the water system, and the Nursing Home Administrator was aware but reported no injuries.
Failure to Complete STAT Imaging and Notify Provider After Resident Fall
Penalty
Summary
A resident with a history of osteoarthritis, previous traumatic fracture, and dementia experienced a fall resulting in complaints of pain to the right wrist and right hip. A physician assistant present at the time assessed the resident and ordered STAT x-rays of the right wrist, pelvis, and hip. Despite these orders, the x-rays were not completed as directed. The facility's process involved contacting a mobile imaging service, but the imaging was not performed the same day, and there was no documentation of follow-up with the provider regarding the delay. Throughout the evening and night following the fall, the resident exhibited signs of significant pain, including shaking and a refusal to ambulate or get out of the wheelchair, which was a change from her baseline. These symptoms were reported to nursing staff, but the provider was not notified of the resident's ongoing pain or the failure to complete the STAT imaging. The facility's policy required immediate notification of the provider and the resident's representative in the event of a significant change in condition or if treatment could not be provided as ordered, but this did not occur. The next morning, the resident was found to be in severe pain and was subsequently sent to the emergency room, where she was diagnosed with fractures to the right hip, pelvis, and wrist. Interviews with facility staff confirmed that the provider was not informed of the delay in imaging or the resident's change in condition until after the resident was sent to the hospital. The failure to complete the STAT x-rays as ordered and to communicate this to the provider resulted in a delay in treatment for the resident.
Failure to Prevent Accident Hazards and Integrate Person-Centered Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with severe cognitive impairment and a history of falls. The resident, diagnosed with Alzheimer's disease and assessed as severely cognitively impaired with a BIMS score of 3 out of 15, was admitted with multiple risk factors including confusion, impulsivity, and a recent history of recurrent falls. Despite the family's provision of detailed information regarding the resident's routines and preferences, such as sleeping in a recliner in street clothes and keeping a specific TV channel on, this information was not incorporated into the resident's baseline or comprehensive care plan, nor was it communicated to frontline staff through the Kardex or other official documentation. The facility's own fall prevention policy required individualized interventions based on assessment and family input, but the care plans lacked person-centered interventions and did not address the resident's behavior of deactivating her own alarm system. Staff relied on educating the resident as a fall prevention measure, despite documentation that the resident was only oriented to self and unable to reliably follow instructions due to severe cognitive impairment. The alarm system intended to alert staff to self-transfers was either not functioning or was turned off at the time of the resident's unwitnessed fall, and there was no documentation of interventions or monitoring related to the resident's known behavior of disabling the alarm. As a result, the resident experienced multiple falls, including an unwitnessed fall that resulted in a left hip fracture requiring surgical intervention. Interviews with staff revealed that key information about the resident's preferences and routines was not available in the care plan or Kardex, and staff were unaware of these preferences, leading to deviations from the resident's established routine. The facility's management acknowledged that person-centered information provided by the family was not integrated into the care planning process, and the care plan did not include goals or interventions to address the resident's behavior of disabling her alarm.
Unnecessary Use of Antipsychotic Medication Without Proper Indication
Penalty
Summary
The facility did not ensure that a resident was free from unnecessary psychotropic medications, as required by policy and regulation. One resident with a diagnosis of Alzheimer's disease with late onset was prescribed Olanzapine, an antipsychotic medication, without an appropriate clinical indication documented in the medical record. The facility's policy states that psychotropic medications should only be used when non-pharmacological interventions are clinically contraindicated and when there is a documented, adequate indication for use. In this case, the physician order listed Alzheimer's disease with late onset as the reason for the antipsychotic, which is not an appropriate indication for such medication. During interviews, the prescribing physician assistant stated that the medication was given due to the resident's severe psychosis, impulsivity, and lack of safety awareness, describing behaviors such as wandering and attempting to stand without assistance. However, these behaviors are common in individuals with Alzheimer's disease and do not necessarily justify the use of antipsychotic medication. The facility failed to document persistent and harmful behaviors or evidence that non-pharmacological interventions were attempted or clinically contraindicated prior to initiating the antipsychotic. As a result, the resident received an unnecessary psychotropic medication without proper justification.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to ensure that residents received care consistent with professional standards to prevent and treat pressure injuries. Two residents, identified as R35 and R44, were affected by these deficiencies. R35, who was at risk for pressure injury development, developed two stage 3 facility-acquired pressure injuries that deteriorated. Observations revealed multiple layers between R35 and the air mattress, and the facility did not provide education or discuss risks versus benefits when R35 declined repositioning. Additionally, staff failed to consistently document repositioning or incontinence care, which contributed to R35's pressure injuries. The prescribed treatment was not applied correctly, as the periwound was not protected during application. R35's care plan was not updated to reflect current wounds and locations, and the repositioning intervention was added 22 days after the development of the pressure injury. Despite the deterioration of R35's moisture-associated skin damage to a stage 3 pressure injury, the facility continued to document this injury on the non-pressure wound tracker. The facility also failed to document repositioning opportunities consistently, with 86 missed documentation instances. During wound care observations, it was noted that the Dakin solution was not properly applied, potentially causing harm to healthy skin. R44 was admitted with a pressure injury that was initially documented as stage 2 but had 50% slough, indicating it was at least stage 3. The facility failed to complete weekly pressure injury assessments per standards of practice, and R44's pressure injury deteriorated, evidenced by undermining and tunneling. Observations also revealed multiple layers between R44 and the air mattress. These failures led to a finding of immediate jeopardy, which was later removed, but the deficient practice continued at a scope/severity of G (actual harm/isolated).
Removal Plan
- Both residents remain at the center and care plan regarding pressure injury reviewed and updated.
- In-house residents with pressure injuries have the potential to be affected. Skin sweep completed.
- Director of nursing or designee implemented re-education with nursing staff (CNAs and licensed nurses) on Pressure Injury and Non-Pressure Injury policy and Use of Support Surface policy.
- Education included the need to ensure care plan is followed including managing moisture and incontinence including not using multiple layers with air mattresses.
- If cares/treatments are refused to notify licensed nurse/DON/designee and education provided on risks and benefits to resident or responsible party, notify MD and update care plan.
- Obtaining Periwound treatment in order from MDs.
- Wound assessments including measurements and ensuring surface area adds up to 100% of assess.
- Identified education will occur prior to start of next scheduled shift.
- Facility reviewed their Pressure Injury and Non-Pressure Injury and Use of Support Surface policies. No changes were required to policies.
- DON/designee also verified that residents with pressure injuries have accurate assessment of pressure injuries, including physician orders for treatment and dressing changes that are completed per MD order.
- Interdisciplinary review completed of care plans for residents with pressure injuries and a visual audit was completed by Director of Nursing or designee to ensure care planned interventions for pressure injury healing and prevention are in place.
- DON/designee to complete random observation (audit) of dressing changes per MD order with periwound treatment, if warranted, and cares/treatment to ensure dressing changes completed per MD order, interventions to promote healing including no multiple layers on air mattresses, and ensure proper documentation of refusal of skin care and treatment.
- Audits will also include Pressure injury weekly documentation to ensure accurate and complete, and CNA task documentation on if cares accepted and documented per care plan.
- Audits will be completed daily. These audits will then continue on varying shifts three times per week for additional weeks then 2 times per week for additional weeks.
- Results of audits will be presented to facility QAPI committee for review and any recommendations.
- Ad hoc QAPI meeting held to review this plan.
Inadequate Staffing Leads to Compromised Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple observations and interviews conducted by surveyors. The staffing levels were based on census and hours per patient day (HPPD) without considering the acuity of the resident population. This resulted in inadequate care, with residents experiencing long wait times for assistance, particularly during weekends when staffing was notably low. The facility's HPPD often fell below the ideal 3.0, with only one day meeting or exceeding this standard. Residents expressed concerns about delayed responses to call lights and untimely meal service, which were corroborated by staff interviews. Several residents, including those with significant care needs such as arthritis, muscle weakness, and cognitive impairments, reported waiting extended periods for assistance with toileting and other activities of daily living. Staff members confirmed that they were unable to complete all necessary care tasks due to insufficient staffing, leading to unmet needs in areas such as oral care and repositioning. The deficiency was further highlighted by observations of inadequate supervision during meal times, where residents requiring assistance were left struggling to eat. Staff interviews revealed that the lack of sufficient personnel often left one CNA responsible for an entire hallway, exacerbating the issue. The facility's failure to adjust staffing levels to accommodate the specific needs of its residents resulted in compromised care and dissatisfaction among both residents and staff.
Sanitation Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 68 residents. During a kitchen tour, a surveyor observed a dietary aide not wearing a beard restraint, which is against the facility's policy on employee sanitary practices. Additionally, garbage cans without lids were found near the food preparation area, and a yellow substance, likely eggs, was spilled in the walk-in refrigerator. The Dietary Manager acknowledged these issues, and the Nursing Home Administrator confirmed the expectation for staff to adhere to hygiene and safety protocols.
Inadequate Infection Control and Staff Surveillance During COVID Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which was evident through multiple observations and interviews. The outbreak that began in October 2024 was prematurely declared resolved, and staff were not aware of the ongoing outbreak, leading to improper source control measures. The facility's policy required the outbreak to be considered resolved only after two incubation periods without new cases, which was not adhered to as the outbreak was ended on day 15. This oversight potentially affected all 68 residents in the facility. During the survey, several staff members, including a Dietary Aide, a CNA, and a Pest Control Contractor, were observed not wearing masks or wearing them incorrectly despite the facility being in a COVID outbreak. Interviews revealed that staff were either unaware of the outbreak or misunderstood the requirements for mask-wearing. The Director of Nursing confirmed the facility had been in outbreak status since early February 2025, yet staff compliance with mask-wearing was inconsistent. The facility's staff surveillance was incomplete, with several instances of staff returning to work too early after reporting symptoms of illness. The staff line list lacked documentation of symptom resolution dates, making it difficult to determine if staff returned to work prematurely. The Infection Preventionist acknowledged these gaps, noting that staff with gastrointestinal symptoms should remain out of the facility for 48 hours after symptoms resolve, which was not consistently followed. Additionally, COVID testing was not documented for staff with symptoms, further indicating lapses in the infection control program.
Cold Dining Room Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the cold temperatures in the dining room. Multiple residents, including those with varying levels of cognitive impairment, were observed wearing jackets or wrapped in blankets to stay warm while dining. The surveyor noted that the dining room temperature was significantly below the facility's policy range of 71 to 81 degrees Fahrenheit, with a recorded temperature of 56.8 degrees Fahrenheit. The issue was acknowledged in a Resident Council meeting, indicating that the facility was aware of the residents' concerns about the cold dining room. Despite this awareness, the problem persisted, as observed by the surveyor over several days. The Nursing Home Administrator (NHA) admitted that the facility needed new boilers and additional insulation to maintain appropriate temperatures, but these measures had not yet been implemented. The surveyor's interviews with staff, including the NHA and a Physical Therapy Assistant, confirmed that the cold temperature was a known issue. The NHA stated that the facility respected residents' choices to eat in the dining room, even when temperatures were low. Maintenance staff did not monitor the ambient temperature, and the NHA acknowledged that the temperature was not acceptable, yet corrective actions were not effectively taken to address the deficiency in a timely manner.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program to support resident choice of activities, based on the comprehensive assessment and care plan and the preferences of each resident. This deficiency was observed in four residents residing on D Hallway, who were not offered or did not participate in meaningful activities. The facility's policy on activities, dated 7/11/22, outlines the importance of designing activities to enhance residents' well-being, cognition, and emotional health, among other aspects. However, the surveyor's observations and record reviews revealed that the facility did not adhere to this policy. One resident, diagnosed with Alzheimer's disease and other conditions, expressed a desire to engage in activities meaningful to her, such as attending religious services, socializing, and participating in various hobbies. Despite these preferences being documented in her care plan, there were numerous days with no activity participation documented, and the resident was observed not participating in any activities during the survey period. Similar patterns were observed with other residents, who also had documented preferences for activities but were not engaged in them, with many days lacking any activity participation documentation. Interviews with staff, including CNAs and the Life Enrichment Specialist, highlighted issues such as understaffing and a lack of activities tailored for residents with dementia. Staff acknowledged the need for more activities and assistance for residents who are not independent in structuring their own activities. The Nursing Home Administrator was aware of the concerns regarding the lack of activities for residents on D Hallway, but the deficiency persisted, indicating a failure to implement an effective activity program that meets the needs and preferences of the residents.
Resident Denied Dignified Clothing Options
Penalty
Summary
The facility failed to ensure a dignified existence and self-determination for a resident who was observed wearing only a hospital gown and gripper socks in the dining room on multiple occasions. The resident expressed discomfort and a preference not to wear a hospital gown, stating that he felt exposed and cold. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview of Mental Status, the resident had no access to his clothes, which were in his assisted living apartment, and had not been offered alternative clothing options by the facility staff. The resident's family lived out of state, and he had no one to bring his clothes from his apartment. The social worker acknowledged the situation and mentioned that arrangements were being made to have the resident's clothes brought to him. However, it was only after the surveyor's inquiry that the social worker considered offering clothes from the facility's lost and found. The resident confirmed that this was the first time he had been offered alternative clothing, highlighting a lapse in the facility's adherence to its policy of respecting and promoting resident rights.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not supporting the food preferences of two residents, R44 and R15. Both residents expressed dissatisfaction with receiving scrambled eggs almost every day for breakfast, despite having communicated their preferences to the kitchen staff. R44, who is cognitively intact with a BIMS score of 15, reported that her meal ticket did not reflect her preference against scrambled eggs. Similarly, R15, with a BIMS score of 13, was observed expressing her dislike for scrambled eggs, which was not addressed by the staff, and her meal ticket also lacked any indication of her preference. The surveyor's observations and interviews revealed that the facility's process for updating meal tickets with resident preferences was not effectively implemented. The Business Office Manager (BOM) acknowledged that substitutions are accommodated but did not offer one to R15 when she expressed her dislike for scrambled eggs. The facility's policy on resident rights emphasizes the importance of honoring resident choices, yet the dietary preferences of R44 and R15 were not updated or respected, leading to a deficiency in promoting resident self-determination.
Failure to Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident verbal abuse within the required timeframe. On February 10, 2025, a resident with a history of verbal aggression, identified as R50, was verbally aggressive towards another resident, R53, causing him to cry. Despite being aware of the incident, key staff members, including the Unit Clerk, Nursing Home Administrator (NHA), Director of Nursing (DON), and a Registered Nurse (RN), did not report the incident to the state agency as required by the facility's policy. The facility's policy mandates that all incidents involving abuse must be reported immediately, but no later than two hours after the incident if it involves abuse. However, the incident was not reported, and the facility did not recognize the resident's verbally aggressive behavior as abuse. Interviews with staff members revealed that R50's behavior was known to be problematic, with several incidents occurring in the bird room where R50 would scream at other residents, including R53, to assert control over the space. Despite the RN and Unit Clerk acknowledging the behavior as verbal abuse, the DON and NHA did not consider it reportable. The DON believed R50's yelling was not directed at R53, while the NHA thought the outbursts were directed at staff rather than residents. This misinterpretation led to a failure to report the incident, violating the facility's policy and state regulations, as the facility did not document a rationale for not reporting the incident.
Failure to Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation was conducted in response to an allegation of resident-to-resident verbal abuse involving two residents, R50 and R53. The incident occurred when R50 changed the TV channel in a shared space, leading to a verbal altercation with R53, who was watching TV. R50's actions and subsequent yelling caused R53 to become visibly upset and leave the room in tears. Despite the incident being reported to the Nursing Home Administrator (NHA) and the Director of Nursing (DON), no formal investigation was initiated. The facility's policy on abuse, neglect, and exploitation requires immediate investigation of any allegations, including interviewing all involved parties and documenting the findings. However, in this case, the facility did not follow these procedures. The DON and NHA reviewed the documentation but did not consider the incident as verbal abuse, and no formal investigation was conducted. Staff members, including RN I, who witnessed the incident, considered it verbal abuse, but their concerns were not adequately addressed. The lack of a thorough investigation is evident as no statements were taken from the involved residents or staff witnesses, and no follow-up was conducted with other residents who might have been affected. The facility's failure to adhere to its policy resulted in an incomplete response to the alleged abuse, leaving the situation unresolved and potentially affecting the well-being of the residents involved.
Failure to Implement Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-centered care plan for a resident diagnosed with schizoaffective disorder, severe obsessive-compulsive disorder, and anxiety. Despite the resident's cognitive intactness and documented behavioral symptoms such as yelling, screaming, and abusive language, the care plan did not address psychosocial well-being or behavioral symptoms. The facility's policy mandates that care plans include measurable objectives and timeframes to meet residents' needs, but this was not adhered to for the resident in question. Interviews with staff, including a Med Tech, CNA, RN, and the Director of Nursing, revealed a lack of specific interventions for managing the resident's behaviors. Staff members attempted to manage the resident's behaviors through verbal de-escalation and redirection, but there were no documented interventions or behavior monitoring orders in the care plan. The Director of Nursing acknowledged the absence of a care plan addressing the resident's behaviors, which would make it difficult for staff to know effective de-escalation interventions.
Failure to Provide Individualized Dementia Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, identified as R50, to maintain their highest practicable physical, mental, and psychosocial well-being. R50, who has a history of verbally aggressive and socially inappropriate behavior, did not have a comprehensive care plan that included their dementia diagnosis or specific goals and interventions for their care. The facility's policy on dementia care emphasizes the need for an interdisciplinary team approach to develop and implement individualized care plans, but this was not adhered to in R50's case. Observations and interviews with facility staff revealed that R50 exhibited behaviors such as yelling, screaming, and using abusive language, which were not consistently documented or addressed with specific interventions. Staff members, including CNAs and nurses, reported that R50 often refused care, medications, and vital sign monitoring, and would become aggressive if disturbed. Despite these behaviors, there were no documented interventions on R50's care plan or CNA Kardex, and staff generally responded by giving R50 space rather than implementing structured interventions. The Director of Nursing acknowledged that R50's behaviors and dementia diagnosis should have been included in the care plan, along with appropriate interventions. The lack of a detailed care plan made it difficult for new employees to understand how to manage R50's behaviors effectively. This oversight resulted in a failure to meet the facility's policy requirements and the resident's care needs, as outlined in the State Operations Manual, Appendix PP, which highlights the importance of addressing behavioral expressions related to dementia through individualized care plans.
Breach of Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the privacy of a resident's medical information, specifically regarding her COVID-19 status. During an interaction outside the facility, a Certified Nursing Assistant (CNA1) disclosed the resident's COVID-19 status in front of other residents and a hospice staff member. This disclosure occurred when the resident questioned why she could not have a shower, and CNA1 responded that it was due to her COVID-19 status. The resident expressed feeling offended by this breach of privacy, and CNA1 later acknowledged that discussing the resident's health status in front of others was inappropriate. Additionally, the Social Services Director (SSD) publicly reprimanded the same resident for not following the facility's smoking protocol. This incident occurred at the front entrance of the facility, where other residents, visitors, and staff could hear the exchange. The resident reported feeling scared and uncomfortable as the SSD approached her closely and continued to reprimand her despite her protests. The Unit Clerk, who witnessed the incident, confirmed that the reprimand was inappropriate in a public setting. The facility's policies on resident rights and privacy were not adhered to in these instances. The Director of Nursing (DON) confirmed that medical information should remain confidential and was unaware of the breach by CNA1. The SSD and DON both denied raising their voices during the smoking protocol incident, although the resident and other staff members reported otherwise. These events highlight a failure to respect the resident's right to privacy and dignity, as outlined in the facility's policies.
Failure to Provide ADL Assistance During COVID Quarantine
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident during a COVID quarantine period. The resident, who was admitted with a primary diagnosis of cervical disc disorder with myelopathy, required assistance with showering and bathing due to an ADL self-care deficit. Despite being scheduled for showers on Mondays, the resident did not receive any showering or bathing services for 21 days, from October 9 to October 29, 2024, while on COVID quarantine. There was no documentation indicating that the resident refused these services. Interviews with staff revealed that the facility's policy was for residents to receive a shower at least once weekly, with bed baths provided on non-shower days. However, due to staffing shortages exacerbated by COVID, the facility struggled to maintain this schedule. The CNA responsible for showers confirmed that residents on COVID quarantine were supposed to receive bed baths, but this did not occur consistently. The Director of Nursing acknowledged the staffing challenges and confirmed that the resident's documentation showed no record of showers or bed baths during the specified period. The resident reported not receiving a shower or bath for over two weeks and not being provided with washcloths or assistance in changing clothes for at least five days. The facility's Administrator was unaware of the issue until the complaint investigation began. The facility had a past non-compliance plan regarding shower documentation, but audits to ensure compliance had not been conducted, and the education for staff on proper documentation was only initiated after the investigation started.
Failure to Provide Timely Post-Fall Assessment
Penalty
Summary
The facility failed to provide timely assessment and care for a resident (R6) after she sustained an unwitnessed fall. According to the facility's Fall Prevention and Management Guidelines, a post-fall assessment should include a physical assessment with vital signs, neuro checks, and immediate notification of any abnormal findings to the physician. However, after R6's fall, there was no immediate assessment conducted by the nurse on duty, RN3. The fall occurred at 12:30 AM, but the physician was not informed until over 24 hours later, and the assessment was not documented until the next day. The resident, who had a history of poor safety awareness and required assistance for transfers, was found on the floor by CNAs, who were instructed to move her without a nurse's assessment. Interviews with staff confirmed that RN3 was aware of the fall but did not assess the resident until the following day. The DON confirmed that the expectation was for immediate assessment and reporting of falls. The resident's care plan indicated she was at risk for falls and had a history of self-transferring unsafely. The failure to follow the facility's policy for fall management and timely assessment led to a deficiency in the quality of care provided to the resident.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, identified as R3, by not following physician orders related to wound care. R3 was admitted with a primary diagnosis of heart failure and had multiple pressure ulcers requiring specific wound care treatment. The care plan indicated that R3 needed extensive assistance with repositioning and hygiene, and was resistive to turning and repositioning. The physician's orders specified cleansing the wound with a wound cleanser, applying skin prep, and using calcium alginate to the wound bed, which was to be covered and secured with a foam border twice daily unless soiled. On a specific date, RN1 did not complete the wound treatment according to the physician's orders. Instead, RN1 applied medi honey to the wound, which was not part of the prescribed treatment, and used paper towels to cleanse the wound, which is not an appropriate method for wound care. The facility's investigation confirmed that RN1 did not follow the physician's orders, and it was noted that the facility was out of the required calcium alginate. RN1 was terminated following this incident and another unrelated incident. The resident, R3, was severely cognitively impaired and refused to be interviewed about the incident.
Deficiency in Providing a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by the lack of functional sinks and hot water. Residents R8 and R7 reported that their bathroom sinks had been inoperative for over a week, requiring them to use sinks down the hallway for personal hygiene. The surveyor observed a musty, mildew odor in their bathrooms, with visible holes and dried drip lines where the sinks had been removed. The Director of Maintenance acknowledged that these issues were on his list to address. Additionally, residents R2, R1, R5, and R3 expressed concerns about not having hot water in their rooms for approximately three weeks. The surveyor confirmed the absence of hot water by recording water temperatures that were significantly below the expected levels. Staff members, including a CNA and an RN, corroborated these issues, noting that they had been ongoing for weeks and affected their ability to provide proper care, such as handwashing and resident showers. The Director of Maintenance indicated that the hot water system had been problematic, with some areas of the building receiving excessively hot water while others had none. Despite replacing several components of the water system, the issue persisted, and additional parts were on order. The Nursing Home Administrator acknowledged the ongoing struggle with the recirculating water system and mentioned the possibility of needing to call a Master Plumber for assistance.
Deficiency in Providing Showers Due to Lack of Hot Water
Penalty
Summary
The facility failed to provide showers to four residents due to a lack of hot water, as evidenced by interviews and record reviews. Residents reported missing showers because the facility did not have hot water available in their hallway. The facility's policy on Activities of Daily Living (ADLs) requires that residents receive necessary services to maintain personal hygiene, including bathing. However, documentation showed that residents were not offered showers on specific dates, and there was no indication that they refused them. This issue affected residents with varying cognitive abilities, including those with intact cognition and those with moderate cognitive impairment. The problem persisted for several weeks, as confirmed by staff interviews. A Certified Nursing Assistant (CNA) and a Registered Nurse (RN) both indicated that the lack of hot water led to missed showers, with staff sometimes resorting to using cold water or transporting hot water from other areas. The Director of Maintenance acknowledged ongoing struggles with the hot water system, having replaced several parts and ordered more to address the issue. The Nursing Home Administrator (NHA) confirmed the inconsistency in hot water availability, particularly in one hallway, which affected the residents' ability to have hot showers.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the self-administration of medications was clinically appropriate for a resident with moderate cognitive impairment. The resident, who was admitted with unspecified dementia, was observed holding a medication cup with pills in her room without staff supervision. The facility had not completed a self-administration of medication assessment for the resident, nor was there a physician order permitting her to self-administer medications. The resident was unsure of the purpose of the pills and requested assistance to cut them, indicating a lack of understanding and potential risk. The facility's policy requires a prescriber's order and an interdisciplinary team assessment to determine the safety and appropriateness of self-administration of medications. However, the registered nurse admitted to leaving the medications with the resident without following these protocols. The Nursing Home Administrator confirmed that the nurse acknowledged the mistake and reiterated the expectation that medications should not be left with residents unless they have been assessed and have a proper order for self-administration.
Failure to Report Alleged Verbal Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by state law. A resident, identified as R7, reported an allegation of verbal abuse through the facility's grievance process, stating that two CNAs were behaving unprofessionally by yelling, screaming, and swearing. Despite the facility's policy requiring immediate reporting of such allegations to the state agency, the Nursing Home Administrator did not report the incident within the mandated two-hour timeframe. R7, who was admitted with a cognitive communication deficit and an intact cognition score, expressed dissatisfaction with the treatment received from CNA G, who allegedly used explicit language and made R7 feel demeaned. The Nursing Home Administrator acknowledged that such behavior could be perceived as abuse, especially by someone with cognitive deficits, but did not report the incident to the state agency, citing a lack of direct evidence that the behavior was directed at R7.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for a resident. The resident, who has a cognitive communication deficit and an unspecified injury of the head, reported an allegation of verbal abuse through the grievance process. The grievance described unprofessional behavior by two CNAs, including yelling, screaming, and swearing. Despite the resident's intact cognition, as indicated by a BIMS score of 13 out of 15, the facility did not conduct a thorough investigation into the allegations. The Nursing Home Administrator acknowledged that such behavior could be perceived as abuse, especially if overheard by a resident. However, the facility did not remove the staff from working with the resident, nor did it conduct a comprehensive investigation. This included failing to collect statements from the involved staff members, interview the resident, or interview other staff or residents who might have witnessed the incident. The facility's inaction left the resident feeling that their concerns were not addressed, and the alleged abusive behavior continued.
Unsafe Hot Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident environments were free from potential accident hazards, specifically concerning hot water temperatures, for three residents. Residents voiced concerns about excessively hot water, and the surveyor confirmed these concerns by recording unsafe water temperatures in the residents' bathrooms. The facility's policy on safe water temperatures mandates that water should not exceed the state's allowable maximum temperature, and staff should monitor residents for signs of burns. However, the surveyor found water temperatures as high as 127.6 degrees Fahrenheit, which poses a risk of burns. The Director of Maintenance acknowledged ongoing issues with the hot water system, including inconsistent water temperatures throughout the facility. Despite replacing several parts of the water system, the problem persisted, with some areas receiving excessively hot water while others had insufficient hot water. The Nursing Home Administrator was aware of the issue but had not reported any injuries resulting from the hot water. The facility's failure to maintain safe water temperatures and adequately address the malfunctioning water system led to the deficiency.
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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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