Friendly Village Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rhinelander, Wisconsin.
- Location
- 900 Boyce Dr, Rhinelander, Wisconsin 54501
- CMS Provider Number
- 525459
- Inspections on file
- 21
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Friendly Village Nursing And Rehab Center during CMS and state inspections, most recent first.
Unlicensed CNA applied a prescribed Lidocaine patch to a resident with cerebral palsy and back pain after a bed bath, even though facility policy allowed only licensed nurses or certified medication technicians to administer medications. The surveyor observed the patch application without a licensed nurse present, and the DON confirmed the CNA was not authorized to administer meds and that the patch was a physician-ordered medication.
Infection control precautions were not followed for two residents. A CNA provided care to a resident on EBP with only gloves, did not perform hand hygiene before care, and used contaminated gloves to apply zinc oxide cream and dress a suprapubic catheter site without changing gloves or cleaning hands between contaminated and clean tasks. Another resident’s urinary catheter drainage bag was observed lying on the floor with the drainage port touching the floor and no protective barrier in place.
The facility failed to properly store resident foods brought in by visitors, as observed by a surveyor who found unlabeled and undated items in refrigerators/freezers. Additionally, the facility did not maintain the correct concentration of chemical sanitizer in the low-temperature dishwasher, with logs showing ppm levels below the required minimum. These deficiencies had the potential to affect the health and safety of residents.
The facility failed to submit complete and accurate staffing data to CMS, affecting all 76 residents. The new HRD, responsible for entering staff hours, faced challenges with agency staff and medication assistants' hours not being accurately reflected. Additionally, staff working longer shifts did not code hours correctly, leading to discrepancies in the Payroll Based Journal reports.
The facility failed to notify residents or their representatives of transfers or discharges, affecting four residents. The facility did not provide notices or inform them of their appeal rights, including necessary contact information and assistance for appeals. This was confirmed through interviews and record reviews.
The facility inaccurately coded the MDS for two residents regarding their PASARR status. One resident's MDS incorrectly stated that a PASARR level 2 screen was not completed, while another resident was wrongly coded as having a serious mental illness requiring a PASARR level 2 screen. The errors were acknowledged by the MDS Coordinator and Social Worker during a surveyor interview.
A resident with multiple health issues experienced significant weight loss due to inadequate assistance with eating and lack of weight monitoring. Despite being at high risk for altered nutrition, the facility failed to reassess the resident's ability to feed herself or update her care plan. Observations showed meals were often left untouched, and staff did not provide necessary help. Communication from the dietitian and therapy department about the resident's needs was not acted upon, leading to a deficiency in maintaining her nutritional status.
Unlicensed CNA Applied Prescribed Lidocaine Patch
Penalty
Summary
The facility did not ensure that only qualified persons administered medications according to residents’ plans of care when an unlicensed CNA applied a Lidocaine external patch 4% to R27’s lower back. The facility policy titled "Administering Medication," revised 01/22/2024, states that only licensed staff may administer or record the administration of medications, and certified medication technicians may administer specific medications only if competency has been determined. R27 was admitted with diagnoses of cerebral palsy and back pain and had a physician’s order for Lidocaine external patch 4% to be applied to the lower back twice daily for pain. On 04/21/2026 at 9:05 AM, the surveyor observed CNA D apply the Lidocaine patch to R27’s lower back after a bed bath. CNA D stated that nurses give the patch to her to put on. The patch had been observed at R27’s bedside before application, and no licensed nurse was observed in the room during the application. The MAR showed RN D’s initials for administration of the Lidocaine patch that morning. Facility staffing records showed CNA D was not a medication administration technician. RN C and DON B both stated that only licensed nurses and certified medication technicians could administer medications, and DON B confirmed CNA D was not allowed to administer medications and that the Lidocaine patch was considered a medication ordered by a physician.
Infection Control Precautions Not Followed During Resident Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not follow standard and transmission-based precautions for two residents. For one resident with cerebral palsy, bowel and bladder incontinence, a suprapubic catheter, and a history of frequent UTIs, Enhanced Barrier Precautions were posted in the room and PPE was available, but a CNA did not perform hand hygiene before care, wore only gloves without a gown, and provided bathing and hygiene care while the resident was incontinent of stool. During the same care, the CNA cleansed the resident’s peri-area and buttocks, then reached into a jar of zinc oxide cream with contaminated gloves and applied the cream to the right buttock without changing gloves or performing hand hygiene. The CNA then cleansed around the suprapubic catheter insertion site with the same gloves and applied a new gauze dressing without changing gloves. For a second resident with an indwelling urinary catheter, the catheter drainage bag was observed lying on the floor near the foot of the bed without a protective barrier, and the urine drainage port was touching the floor.
Improper Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to store resident foods brought in by visitors in a manner that prevents food-borne illness. During an initial tour, a surveyor observed two refrigerators/freezers in the nurse station on the main level of the facility containing various foods and beverages that were not labeled with resident names or dated with received and use-by dates. This practice had the potential to affect 59 of the 76 residents residing on the main level. The Registered Dietician (RD) and Nursing Home Administrator (NHA) were unable to confirm ownership of the items, and the facility could not ensure that the foods were not outdated and safe for consumption. Additionally, the facility did not maintain the correct concentration of chemical sanitizer in the low-temperature dishwasher as per the manufacturer's guidelines. The dish machine logs showed that the parts per million (ppm) of the chemical sanitizer were consistently below the required minimum of 50 ppm on several occasions. The Dietary Manager (DM) was not informed of these low readings, and there was no evidence that the dish machine was checked or serviced to address the issue. This deficiency had the potential to affect all 76 residents served by the facility's kitchen. The surveyor's review of the facility's policies revealed that the Resident Food Brought in by Family or Visitors policy was not dated, and the Dishwashing Procedure policy did not specify the required ppm for the chemical sanitizer. The facility's failure to adhere to these policies and ensure proper labeling and dating of resident foods, as well as maintaining the correct chemical sanitizer concentration, posed a risk to the health and safety of the residents.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to ensure that the mandatory staffing data submitted to CMS from July 1, 2024, to September 30, 2024, was complete, accurate, and auditable. This deficiency potentially affects all 76 residents residing in the facility. The facility's policy requires the submission of complete and accurate direct care staffing information, including agency and contracted staff, based on payroll and other verifiable data. However, the Payroll Based Journal (PBJ) Staffing Data Reports indicated excessively low weekend staffing during the specified period, with a notable decrease in staffing percentages compared to the previous quarter. The deficiency was attributed to several issues in the facility's reporting process. The Human Resource Director (HRD), who was new and still undergoing training, was responsible for entering electronic timekeeping staff hours, which were then submitted to the corporate office for PBJ reporting. The facility's system did not accurately reflect the hours of agency staff and medication assistants (MAs) who also worked as Certified Nursing Assistants (CNAs). Additionally, staff working longer than 8-hour shifts, particularly those on 12-hour shifts, were not coding their hours correctly. These discrepancies were not identified by the facility until brought to their attention by the surveyor, and no corrective plan had been developed at the time of the survey.
Failure to Provide Transfer Notification and Appeal Rights
Penalty
Summary
The facility failed to provide timely notification of transfer or discharge to residents or their representatives, affecting four sampled residents. The facility did not issue a notice of transfer prior to facility-initiated discharges for these residents, nor did it inform them of their appeal rights, including the necessary contact information and assistance for submitting an appeal. This deficiency was identified through interviews and record reviews conducted by the surveyor. The report highlights specific cases where the facility did not comply with its policy on transfer and discharge notifications. For instance, one resident with intact cognition was transferred to the hospital without prior notice. Another resident with severe cognitive impairment, who had a Power of Attorney, was also transferred without notification. Similar issues were found with two other residents, one of whom had intact cognition and another with severe cognitive impairment. The Business Office Manager confirmed that the facility was not providing the required information at the time of transfer.
Inaccurate MDS Coding for PASARR Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents regarding their Preadmission Screening and Resident Review (PASARR) status. For one resident, identified as R18, the MDS assessment incorrectly indicated that a PASARR level 2 screen had not been completed, despite the fact that it was completed on March 3, 2022. This resident was admitted with diagnoses including depression, anxiety, and PTSD, and the error was found in the comprehensive MDS assessment dated January 13, 2025. For another resident, identified as R48, the MDS assessment inaccurately coded the resident as having a serious mental illness, which would necessitate a PASARR level 2 screen. However, the resident's delusions were attributed to progressive dementia, as noted in the hospital discharge summary dated August 4, 2021, indicating that a level 2 PASARR was not necessary. The comprehensive MDS assessment dated April 24, 2024, correctly stated that no PASARR level 2 had been completed, but it conflicted with another section of the MDS that suggested a psychotic disorder was present. The MDS Coordinator and Social Worker acknowledged the coding errors during an interview with the surveyor.
Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident, identified as R5, maintained acceptable nutritional status. R5, who was at high risk for altered nutrition, did not receive the necessary assistance with eating, and weights were not obtained for over 60 days. Despite a significant weight loss of 11.17% over this period, the facility did not reassess R5's ability to feed herself or address the weight loss in her care plan. The facility's policy required weights to be retaken within 24 hours for verification if there was a weight change of 5 pounds or greater within 30 days, but this was not followed. R5 was admitted with multiple diagnoses, including osteoarthritis, type 2 diabetes, major depressive disorder, dysphagia, muscle wasting, and chronic pain. Her care plan indicated a need for adaptive equipment and assistance with meals, yet observations showed that R5 was often left without the necessary help to eat. On several occasions, surveyors observed R5's meals untouched, and staff did not provide the required assistance. Despite communication from the Registered Dietitian and therapy department indicating R5's need for more assistance, no new interventions were added to her care plan. Interviews with facility staff revealed a lack of documentation and follow-up on R5's weight loss and feeding needs. The Director of Nursing acknowledged the failure to track and document weights properly. Additionally, the Speech and Language Pathologist confirmed that therapy had not reevaluated R5 despite changes in her feeding status. This lack of action and communication contributed to the deficiency in maintaining R5's nutritional status.
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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