Fond Du Lac Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Fond Du Lac, Wisconsin.
- Location
- 244 N Macy St, Fond Du Lac, Wisconsin 54935
- CMS Provider Number
- 525655
- Inspections on file
- 29
- Latest survey
- September 5, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Fond Du Lac Lutheran Home during CMS and state inspections, most recent first.
A resident with a history of hepatic encephalopathy and moderate cognitive impairment eloped from a facility due to inadequate supervision. Despite being assessed as high risk for elopement and having a WanderGuard, the resident managed to remove the device and leave the facility without staff knowledge. The facility failed to implement effective interventions and supervision, leading to a finding of Immediate Jeopardy.
A resident's bathroom was found with BM soiled cloths on the sink, indicating a failure to maintain a sanitary environment. The resident, who had no cognitive impairment, expressed concerns about cleanliness. A Medication Technician confirmed the improper handling of soiled linens, and the Director of Nursing acknowledged the lack of a specific policy for handling soiled items.
A CNA at the facility did not complete the required 12 hours of in-service training during their anniversary hire year, having only completed 7.25 hours. The training lacked coverage of the QAPI process. Despite communication efforts by the NHA, the CNA did not fulfill the training requirements.
The facility did not have written policies and procedures for a facility closure, potentially affecting all 56 residents. The NHA stated that the facility would follow state regulations but acknowledged the absence of a formal policy.
The facility did not implement its policies for preventing abuse, neglect, and theft by failing to conduct timely background checks for two CNAs. The BID forms for these CNAs were not dated, and there was no proof of completion within the required timeframe. The Assistant Nursing Home Administrator confirmed the issue, and no response was received from Human Resources for clarification.
A resident with a pacemaker was admitted to a facility without a care plan for pacemaker use, leading to a hospital admission after the pacemaker's battery expired. Despite the resident's history of heart issues, the facility did not schedule cardiologist appointments or monitor the pacemaker, resulting in a critical drop in heart rate. Staff interviews revealed a lack of protocol for managing residents with pacemakers, contributing to the oversight.
The facility failed to thoroughly investigate allegations of abuse and misappropriation involving two residents. One resident, with intact cognition, reported verbal abuse by a CNA, but the investigation lacked immediate staff education. Another resident, with moderately impaired cognition, reported missing money, but the investigation was delayed and lacked follow-up on emotional needs. The facility's investigations were incomplete, lacking timely interviews, staff education, and follow-up with the affected residents.
The facility failed to maintain adequate staffing levels, resulting in delayed care for residents. Observations and interviews revealed that CNA-to-resident ratios were not met, leading to long wait times for call light responses and incomplete care. Residents reported delays in receiving assistance, and staff expressed concerns about being unable to complete tasks due to insufficient staffing. The facility had stopped using agency CNAs, exacerbating the staffing shortages.
The facility compromised the dignity of three residents by serving meals on disposable dishware due to a kitchen staffing shortage. Meals were served in Styrofoam containers with plastic utensils, which residents found difficult to use. The Dietary Manager confirmed the use of Styrofoam was due to staffing issues and acknowledged it was not a home-like option. Residents expressed dissatisfaction, with one keeping silverware in their room to avoid using plasticware.
A facility failed to ensure a resident with a legal guardian had court-ordered protective placement, as required by law. The resident, with severe cognitive impairment and multiple diagnoses, lacked the necessary protective placement paperwork. The social worker was unaware of this requirement and had not secured the placement, although they contacted the Aging and Disability Resource Center for guidance.
A resident with diabetes and dementia was observed self-administering insulin without a documented assessment or physician's order. Despite having intact cognition, the facility failed to ensure the necessary protocols were followed, as confirmed by the DON.
A resident with intact cognition experienced verbal and mental abuse from another resident, who used offensive language and derogatory remarks. Despite staff awareness of the behavior, the facility did not consider it willful abuse, failing to protect the resident from emotional distress.
A facility failed to report an allegation of verbal abuse involving a resident, who was distressed by another resident's offensive language. Despite the facility's policy requiring immediate reporting of abuse allegations, the Nursing Home Administrator was not informed until two days later and decided not to report the incident to the State Agency, concluding it did not constitute willful abuse.
A resident at risk for pressure injuries due to dementia and immobility did not receive the required care as outlined in their care plan. Observations and staff interviews revealed that the resident was left in a recliner for extended periods without repositioning, contrary to the care plan's requirements. Staff were unaware of the repositioning schedule, and the facility lacked a specific policy for repositioning.
A resident with a urinary catheter and neurogenic bladder experienced delays in receiving assistance with ADLs. The resident activated the call light, but a Nurse Extern turned it off without providing care, resulting in a 31-minute wait. The Director of Nursing acknowledged the issue, stating that call lights should remain on until care is delivered.
A resident with COPD had an unsecured oxygen cylinder stored upright in their room closet, contrary to the facility's policy requiring oxygen cylinders to be secured. This was observed by a surveyor and confirmed by staff, including an RN, the Facility Manager, and the DON, yet the issue persisted.
A resident with a history of colectomy and ileostomy did not receive appropriate care, leading to stool leakage due to overfilled bags and ill-fitting supplies. The facility lacked specific care orders and documentation, and staff were unfamiliar with the resident's needs.
A facility failed to assess and care plan the use of bed rails for a resident with severely impaired cognition. The resident, who had an activated POAHC, signed a consent form for bed rail use, which should have been signed by the POAHC. The facility lacked a policy for bed rail use, and the necessary assessment was not completed.
A Nurse Extern improperly disposed of an oxycodone tablet in the trash bin instead of following the facility's policy for controlled drug disposal, which requires the presence of two licensed healthcare professionals and proper documentation. The NE-O retrieved the medication and disposed of it in a drug disposal bottle without a second witness and failed to document the destruction in the narcotic log book.
The facility failed to properly label and date medications for several residents, leading to incorrect dosing and administration times. Observations showed that insulin vials and ophthalmic solutions were not dated when opened, and expired vaccines were found in the medication refrigerator. These actions violated the facility's medication storage policy.
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies. A CNA did not adhere to proper hand hygiene protocols while providing care to a resident with an indwelling catheter. Another CNA did not don appropriate PPE while providing incontinence care to a resident on Enhanced Barrier Precautions (EBP). Additionally, the facility failed to implement EBP for two other residents, one with a gastrostomy tube and another with a stage 4 sacral decubitus pressure injury.
The facility failed to ensure proper treatment and care for a resident with diabetes mellitus by not obtaining detailed physician orders for insulin and blood sugar monitoring, not assessing the resident's ability to self-administer insulin, and not monitoring for signs of hypo/hyperglycemia. The facility also lacked a diabetic management policy.
The facility failed to investigate a fall and implement safety interventions for a resident with intellectual disabilities, bipolar disorder, dementia, and epilepsy. Despite a witnessed fall documented by a Hospice RN, the facility did not complete a follow-up investigation or implement safety precautions, leading to additional falls and injury.
A resident received IV fluids through an implanted port administered by an LPN who was not qualified to perform the procedure. The facility failed to ensure that an RN was present to supervise the LPN, as required by state regulations.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was assessed as being at high risk for elopement. The resident, who had a history of hepatic encephalopathy, alcoholic cirrhosis of the liver, delirium, anxiety disorder, depression, and a history of falling, was ambulatory and used a walker and wheelchair for mobility. Despite being assessed as having moderate cognitive impairment, the resident was able to cut off a WanderGuard bracelet and elope from the facility without staff knowledge on multiple occasions. The resident's elopement risk was initially assessed as low, but after several incidents of wandering and increased confusion, the risk was reassessed as high. The facility placed a WanderGuard on the resident, but the resident managed to remove it multiple times. On one occasion, the resident left the facility and returned from a local store without staff knowledge. The facility's failure to implement effective interventions and supervision for the resident, despite the known risk and history of elopement attempts, led to the deficiency. Staff interviews and record reviews revealed that the facility did not have adequate measures in place to monitor the resident effectively. The resident's care plan included interventions such as structured activities and frequent checks, but these were not consistently implemented. The facility's lack of immediate and effective response to the resident's elopement risk and behavior resulted in a finding of Immediate Jeopardy.
Removal Plan
- Reviewed the facility's Elopement Prevention Policy and updated elopement protocol.
- Provided all staff education regarding supervision for residents at risk for elopement and steps to take if a resident cuts off a WanderGuard, requests a tool to cut off a WanderGuard, and/or continues to express a desire to leave the unit.
- Removed plaques at each stairwell doorway that contained a code to enter and exit the unit and placed a small label with the door code at the top of the door frame.
- Conducted a thorough sweep of all residents for elopement risk and exit-seeking behavior and ensured care plans were updated with interventions to address exit-seeking/unsafe behavior and/or statements to ensure safety.
- Initiated audits of residents with exit-seeking behavior for proper documentation, effectiveness of interventions, and elopement events. Audit results will be brought to the Quality Assurance Performance Improvement committee for review.
Deficiency in Maintaining a Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment for a resident, identified as R5, who was observed with bowel movement (BM) soiled cloths on the bathroom sink. R5, who had no cognitive impairment and was responsible for their own healthcare decisions, expressed dissatisfaction with the cleanliness of the bathroom. The observation was made during a surveyor's visit, and the presence of the soiled cloths was confirmed by a Medication Technician (MT-C) who had assisted with R5's care earlier that day. MT-C acknowledged that soiled linens should not be placed on the sink and should be bagged and taken to the utility room. The Director of Nursing (DON-B) confirmed that the facility's usual practice is to place soiled linens directly in a bag for transport to the utility room, and verified that the soiled cloths should not have been left on the sink. However, the facility lacked a specific policy addressing the handling of soiled items, as the provided Standard Activities of Daily Living (ADL) Protocol did not include instructions on where staff should place soiled items during care. This oversight contributed to the deficiency observed in maintaining a clean and safe environment for the resident.
Deficiency in CNA Training Compliance
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as CNA-D, completed the required 12 hours of in-service training during their most recent anniversary hire year. CNA-D was hired on August 23, 2023, and by the time of the survey, had only completed 7.25 hours of the required training. This included 2.25 hours of electronic training and attendance at five staff meetings. The training completed did not cover all required topics, specifically missing the Quality Assurance and Performance Improvement (QAPI) process. The Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged the deficiency, noting that CNA-D had not completed the online training by the due date and had overdue trainings. Despite efforts to communicate the training requirements through emails, CNA-D did not respond or complete the necessary training. The facility's failure to ensure CNA-D's compliance with training requirements was identified during a review of records and staff interviews conducted by the surveyor.
Lack of Facility Closure Policies
Penalty
Summary
The facility was found to lack policies and procedures for handling a facility closure, which could potentially impact all 56 residents. During an interview, the Nursing Home Administrator (NHA) indicated that the facility would adhere to state regulations in the event of a closure but admitted that there was no written policy in place to guide such an event.
Failure to Conduct Timely Background Checks for CNAs
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse, neglect, and theft by not ensuring thorough and timely background checks for two Certified Nursing Assistants (CNAs), identified as CNA-C and CNA-D. The facility's policy requires screening of employees, including verification of references, certification, and criminal background checks before they are allowed to work with residents. However, during a review, it was found that the Background Information Disclosure (BID) forms for CNA-C and CNA-D were not dated, and there was no proof that these forms were completed within the required timeframe. CNA-C, who was hired in 2004, did not have a BID form completed within the previous four years. Similarly, CNA-D, who was rehired in 2024, also lacked a dated BID form, and there was no evidence that the form was completed prior to or on the date of rehire. The Assistant Nursing Home Administrator confirmed the absence of dates on the BID forms and was unsure of the reason. Despite attempts to contact Human Resources for clarification, no response was received by the surveyor.
Failure to Monitor Pacemaker Leads to Hospitalization
Penalty
Summary
The facility failed to ensure proper care and treatment for a resident with a pacemaker, leading to a significant health event. The resident, who had a history of acute congestive heart failure, symptomatic bradycardia, and sick sinus syndrome, was admitted to the facility with a pacemaker. Despite the resident's moderate cognitive impairment, they were responsible for their healthcare decisions. The facility did not have a care plan in place for the resident's pacemaker use, and there was no follow-up care or scheduled appointments with a cardiologist to monitor the pacemaker's functionality. This oversight resulted in the resident being admitted to the hospital after the pacemaker's battery expired, causing the resident's heart rate to drop to the 30s. Interviews with facility staff revealed a lack of awareness and protocol regarding the management of residents with pacemakers. The Assistant Director of Nursing and other staff members acknowledged that there was no process in place for residents admitted with pacemakers, and the resident's stable vital signs did not alert them to the need for monitoring. The Medical Doctor was aware of the pacemaker but did not ensure follow-up care, and there was confusion about who was responsible for checking the pacemaker. The resident and their family were also noted to have some responsibility, as the pacemaker transmitter from the resident's home was not brought to the facility upon admission.
Deficient Investigation of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and misappropriation involving two residents. For the first resident, who had intact cognition and multiple medical conditions including type 2 diabetes and chronic kidney disease, an allegation of verbal abuse by a Certified Nursing Assistant (CNA) was reported. The investigation concluded without including staff education on abuse, neglect, and misappropriation. The Assistant Nursing Home Administrator (ANHA) was unaware that immediate education was necessary following a substantiated abuse allegation, which resulted in the employee's termination. The second resident, with moderately impaired cognition and conditions such as type 2 diabetes and anxiety, reported missing money from their dresser drawer. The investigation into this misappropriation was delayed, with the resident and like residents not interviewed until several days after the report. The investigation lacked documentation of follow-up with the resident regarding their emotional needs, and there was no evidence of staff education or interventions to safeguard the resident's belongings. The ANHA acknowledged the lack of follow-up and resolution, as the facility did not find evidence of theft and the money was not replaced. Overall, the facility's investigations were incomplete, lacking timely interviews, staff education, and follow-up with the affected residents. The deficiencies in the investigation process and the failure to provide immediate education and emotional support to the residents highlight significant gaps in the facility's handling of abuse and misappropriation allegations.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the care needs of its residents, as evidenced by the review of staffing shifts and interviews with residents and staff. The facility's staffing plan, as outlined in the Facility Assessment, was not adhered to on 15 out of 30 shifts reviewed. Specifically, the Certified Nursing Assistant (CNA)-to-resident ratios were not met, leading to delayed response times to call lights and incomplete resident care. Observations and interviews revealed that call lights were not answered in a timely manner, and residents experienced delays in receiving necessary care. One resident, who had a urinary catheter and intact cognition, reported long wait times for call light responses, sometimes resorting to using a cell phone to contact staff. On one occasion, the resident waited 31 minutes for assistance after a nurse extern turned off the call light without providing the requested service. Another resident experienced a 37-minute wait for assistance after activating their call light. These delays in care were corroborated by multiple resident interviews, where concerns were raised about the timeliness and completeness of care, including issues with shower schedules and hygiene maintenance. Staff interviews further highlighted the staffing deficiencies, with CNAs expressing that they often felt rushed and unable to complete tasks adequately due to insufficient staffing levels. The facility had stopped using agency CNAs, which contributed to the staffing shortages. Staff reported being frequently asked to work extra hours and feeling pressured to rush through resident care. The Nursing Home Administrator acknowledged the staffing challenges and the facility's failure to meet the staffing ratios outlined in the Facility Assessment.
Dignity Compromised by Use of Disposable Dishware
Penalty
Summary
The facility failed to maintain the dignity of three residents by serving meals on disposable dishware, specifically Styrofoam containers and plastic utensils, due to a staffing shortage in the kitchen. On the morning of July 8, 2024, breakfast was served in Styrofoam containers, and during lunch, beverages were served in Styrofoam cups. Residents expressed dissatisfaction with the use of plastic utensils, which made it difficult to cut food, and one resident reported that their Cream of Wheat was served cold. Another resident mentioned keeping silverware in their room to avoid using plasticware, which they found difficult to handle due to mobility issues. The Dietary Manager confirmed that the use of Styrofoam was due to insufficient kitchen staff and acknowledged that it was not a home-like option for residents. The manager also stated that regular silverware should be provided unless a resident is on precautions, in which case disposable ware is used. However, the manager was unsure why some residents received plasticware when not on precautions. The use of Styrofoam cups for extra fluids was attributed to the lack of large enough cups, although the manager noted that the kitchen supplied plenty of plastic drink cups and coffee cups to the units.
Failure to Ensure Protective Placement for Resident with Legal Guardian
Penalty
Summary
The facility failed to ensure that a resident with a legal guardian had court-ordered protective placement in the least restrictive environment, as required by law. The resident, who was admitted with diagnoses including unspecified intellectual disability, senile degeneration of the brain, bipolar disorder, and dementia with behavioral disturbance, was severely cognitively impaired and had a guardian as a decision maker. Despite having Letters of Guardianship dated back to 1994, the facility did not have the necessary protective placement paperwork for the resident. The social worker at the facility was unaware of the requirement for protective placement and had not ensured it was obtained, although they had contacted the Aging and Disability Resource Center to inquire about it.
Lack of Assessment and Physician's Order for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R45, had a self-administration of medication assessment or a physician's order to self-administer medication. R45, who was admitted with diagnoses including diabetes mellitus and dementia, had a Minimum Data Set (MDS) assessment indicating intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Despite this, there was no documented assessment or physician's order authorizing R45 to self-administer insulin. During an observation, a Nurse Extern (NE) was seen drawing up insulin and handing it to R45, who then self-injected the insulin. The Director of Nursing (DON) confirmed that R45 did not have the necessary assessment or physician's order for self-administration of insulin, which was expected to be completed by the staff before allowing such practice.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect a resident, R305, from verbal and mental abuse by another resident, R14. R305, who had intact cognition, reported feeling distressed and emotionally affected by R14's offensive language and behavior. R14, who also had intact cognition, was documented to have used derogatory language towards R305 and other residents, causing emotional distress. Despite being aware of R14's behavior, the Nursing Home Administrator did not consider the altercation between R14 and R305 as willful abuse. Multiple staff members, including registered nurses and a medication technician, confirmed R14's habit of using foul language and making negative comments about other residents within earshot. R14's behavior was documented in a behavior note, and staff interviews revealed that R14 often expressed agitation and made threats towards other residents. The facility's policy mandates immediate reporting of abuse, but the response to R14's behavior did not align with this policy, resulting in a failure to ensure an environment free from abuse for R305.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident, R305, to the State Agency as required by their policy. The incident involved a conflict between R305 and another resident, R14, where R14 used offensive language towards R305, causing emotional distress. Despite the facility's policy mandating immediate reporting of abuse allegations, the Nursing Home Administrator (NHA) was not informed of the incident until two days later and concluded that the altercation did not constitute willful abuse, thus not reporting it to the State Agency. R305, who has intact cognition as indicated by a BIMS score of 15 out of 15, reported feeling distressed by R14's behavior, which included derogatory remarks. R14, who also has intact cognition with a BIMS score of 13 out of 15, has a history of physical behavior directed towards others. The facility's failure to report the incident promptly and appropriately reflects a deficiency in adhering to their abuse reporting policy.
Failure to Implement Comprehensive Care Plan for Resident at Risk of Pressure Injuries
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident identified as R50, who was at risk for developing pressure injuries due to dementia and immobility. The care plan included interventions such as routine toileting, skincare for incontinence, repositioning every 2-3 hours, and the use of pressure-reducing devices. However, observations and staff interviews revealed that these interventions were not consistently followed. R50 was frequently observed in a recliner for extended periods without repositioning, contrary to the care plan's requirements. Staff interviews indicated a lack of awareness and adherence to the care plan. A nurse extern and a CNA both acknowledged that R50 was not repositioned as often as required, with the CNA noting that R50 was sometimes left in the recliner all day. The Director of Nursing confirmed that staff should assist R50 with bathroom needs and repositioning every 2-3 hours, but this was not consistently practiced. The facility also lacked a specific policy for repositioning, contributing to the deficiency in care for R50.
Delayed Assistance with ADLs for Resident
Penalty
Summary
The facility failed to provide timely and consistent assistance with activities of daily living (ADLs) for a resident, identified as R2, who had a urinary catheter and was diagnosed with neurogenic bladder. R2 had intact cognition, as indicated by a BIMS score of 15 out of 15. On two separate occasions, R2 experienced delays in receiving care after activating the call light. On the first occasion, R2 waited 31 minutes for assistance after the call light was turned off by a Nurse Extern (NE-O) who informed R2 that a Certified Nursing Assistant (CNA-N) would assist after returning from break. On the second occasion, NE-O again turned off the call light without providing care, resulting in a delay until CNA-N returned from break to change R2's brief. The surveyor's observations and interviews with R2, NE-O, and CNA-N confirmed the delay in care and the inappropriate practice of turning off the call light before care was provided. The Director of Nursing (DON-B) acknowledged the issue, stating that call lights should remain on until care is delivered and that a 31-minute response time is longer than expected. This deficiency highlights a lapse in the facility's protocol for responding to residents' needs in a timely manner, particularly for those requiring assistance with ADLs.
Unsecured Oxygen Cylinder in Resident's Room
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards for one resident, identified as R14, who was part of a sample of 19 residents. R14, who has a diagnosis of chronic obstructive pulmonary disease (COPD), had an unsecured oxygen cylinder stored upright in their room closet. The facility's policy on the safe use of oxygen, dated 11/8/23, requires that oxygen cylinders be secured in an upright position. On 7/8/24, a surveyor observed the unsecured oxygen cylinder in R14's closet. Subsequent interviews with RN-D, the Facility Manager, and the Director of Nursing confirmed the oxygen cylinder was unsecured and should have been properly secured according to facility policy. Despite these acknowledgments, the surveyor observed the unsecured oxygen tank again on 7/10/24.
Inadequate Ileostomy Care for Resident
Penalty
Summary
The facility failed to provide appropriate ileostomy care for a resident, identified as R12, who had a medical history of colectomy with end ileostomy. R12's care plan did not include ileostomy care, leading to issues such as stool leakage from the ileostomy dressing. The resident reported that the ileostomy collection bag was not emptied in a timely manner over a weekend, causing it to overfill and leak multiple times. Additionally, the facility used ill-fitting ostomy supplies, resulting in further leakage. Nursing notes documented instances of stool leakage and appliance changes due to these issues. The facility lacked specific orders for R12's ileostomy care, and the Treatment Administration Record did not document routine ileostomy care. Interviews with staff revealed a lack of familiarity with R12's ostomy care needs, and the facility did not have a policy on ostomy care. The Assistant Director of Nursing acknowledged that orders for ostomy care were not resumed after R12 returned from a hospitalization, and there was an expectation for staff to document ostomy care, which was not met.
Failure to Assess and Care Plan Bed Rail Use
Penalty
Summary
The facility failed to ensure the proper assessment and care planning for the use of bed rails for a resident, identified as R38. R38 was observed with half rails on their bed, but there was no documented risk assessment for their use. Additionally, a risk versus benefits statement was signed by R38, despite R38 having an activated Power of Attorney for Healthcare (POAHC) due to severely impaired cognition, as indicated by a BIMS score of 5 out of 15. The facility lacked a policy for the use of bed rails, and the Director of Nursing confirmed that the side rail consent and release form should have been signed by R38's POAHC. Furthermore, although there was a side rail assessment available in the electronic medical record, it was not completed for R38.
Improper Disposal of Controlled Drug by Nurse Extern
Penalty
Summary
The facility failed to ensure the proper disposal of a controlled drug for one resident, identified as R22, during a medication administration review. A Nurse Extern (NE-O) was observed disposing of an oxycodone 5 mg tablet, a Schedule IV opioid medication, in the medication cart trash bin. When questioned by the surveyor, NE-O admitted to not knowing why the medication was discarded in such a manner and typically placed discarded medication in a bottle. NE-O retrieved the oxycodone tablet from the trash, along with a gabapentin 600 mg tablet and a methocarbamol 500 mg tablet, and subsequently disposed of them in a Destroyer Drug Disposal bottle without verifying the medication with a second witness. The facility's policy requires that medication destruction occurs in the presence of at least two licensed healthcare professionals, and the destruction must be documented in the narcotic log book. NE-O failed to adhere to these procedures, as there was no second witness present during the disposal, and the destruction of the oxycodone was not documented. This incident highlights a breach in the facility's medication disposal policy, which mandates specific steps to ensure controlled substances are disposed of safely and accurately.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled and dated appropriately for six residents during medication administration. Observations revealed that staff administered open and undated medications to these residents, which included tamsulosin HCL, Admelog insulin, gabapentin, and ophthalmic solutions. In one instance, a nurse extern administered the wrong dose of tamsulosin HCL to a resident due to an incorrect label and administered a medication at the wrong time to another resident. Additionally, the insulin vials used for multiple residents were not dated when opened, contrary to the facility's policy. Further inspection of the second-floor medication refrigerator uncovered an open and undated multi-dose vial of octreotide acetate and four syringes of expired influenza vaccine. The facility's policy mandates that medications be labeled with an open date and that expired medications be removed and destroyed. However, these protocols were not followed, as evidenced by the presence of expired vaccines and undated vials in the medication storage area.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. Certified Nursing Assistant (CNA)-M did not adhere to proper hand hygiene protocols while providing care to a resident with an indwelling catheter. CNA-M failed to perform hand hygiene between glove changes and did not change gloves between dirty and clean tasks during a bed bath and incontinence care. This was confirmed by the Director of Nursing (DON)-B, who acknowledged the lapse in protocol. Another deficiency was observed with CNA-N, who did not don appropriate personal protective equipment (PPE) while providing incontinence care to the same resident on Enhanced Barrier Precautions (EBP) due to a urinary catheter. Despite the presence of a PPE cart and signage indicating EBP, CNA-N only wore gloves and did not use a gown, contrary to facility policy. DON-B confirmed that staff should don full PPE for residents on EBP. Additionally, the facility failed to implement EBP for two other residents. One resident with a gastrostomy tube did not have appropriate signage or a PPE cart outside their room, and another resident with a stage 4 sacral decubitus pressure injury was not on the facility's EBP list. The DON confirmed these oversights, acknowledging that both residents should have been on EBP with proper signage and PPE availability.
Failure to Monitor and Manage Diabetes Care
Penalty
Summary
The facility did not ensure treatment and care in accordance with professional standards of practice for a resident with diabetes mellitus. The resident's medical record lacked detailed physician orders for insulin and blood sugar monitoring, and there was no assessment for the resident's ability to self-administer insulin or perform accuchecks. Additionally, the facility failed to monitor the resident's insulin use and blood sugar levels or check for signs and symptoms of hypoglycemia or hyperglycemia. The resident's care plan indicated that staff should monitor for these signs, but there was no documented proof of such monitoring in the medical record. The resident was admitted with an insulin pump and had a discharge summary that included an order for Humalog but no orders for blood sugar monitoring. The medical record did not contain insulin pump orders or orders for the frequency of blood sugar monitoring. The Director of Nursing confirmed that the facility did not assess the resident for diabetic management and that there were no documented records of the resident's insulin use or blood sugar results. The facility also lacked a diabetic management policy, which contributed to the oversight in monitoring and managing the resident's diabetes care.
Failure to Investigate and Prevent Falls
Penalty
Summary
The facility did not ensure a fall was thoroughly investigated to determine root cause, implement appropriate interventions to prevent reoccurrence, or ensure the environment was as free from accident hazards as possible for one resident. On 3/19/24, a Hospice RN documented that the resident had a witnessed fall, but the facility did not complete a follow-up investigation or implement safety precautions to prevent further falls. The resident subsequently experienced additional falls on 3/23/24 and 3/27/24, with the latter resulting in a 1-inch reddened area on the forehead. The facility's Falls policy, reviewed on 6/24/22, mandates preventative measures to reduce falls and injuries, including completing a Fall Incident Report, updating care plans with identified interventions, and conducting follow-up assessments. However, the facility failed to adhere to this policy for the resident, who had a history of intellectual disabilities, bipolar disorder, dementia with behavioral disturbances, and epilepsy. The Assistant Director of Nursing acknowledged that the facility did not complete a fall investigation or implement safety interventions following the initial fall on 3/19/24.
LPN Administered IV Fluids Without Proper Qualifications
Penalty
Summary
The facility did not ensure that intravenous (IV) therapy treatment was administered by competent staff for one resident. On 11/18/23, an LPN administered IV fluids to a resident through the resident's implanted port, despite not being qualified to do so. The resident had been admitted with diagnoses including malignant neoplasm of the brain and protein-calorie malnutrition and had moderate cognitive impairment. The LPN administered the IV fluids without the direct supervision of an RN, as required by Wisconsin State Legislature Chapter N 6, which mandates that LPNs perform acts in complex patient situations under the direct supervision of an RN or provider. The Director of Nursing (DON) confirmed that the LPN was IV certified but not trained to access central lines, such as implanted ports. The facility's contracted pharmacy's Registered Nurse Educator (RNE) also verified that the certification courses did not cover central lines, as LPNs are not allowed to access them in Wisconsin. On the day of the incident, an RN was not present in the facility during the PM shift when the LPN administered the IV fluids. The DON acknowledged that an RN manager or the previous DON should have come in to administer the order, highlighting a lapse in ensuring proper supervision and competency in IV therapy administration for complex patient situations.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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