Golden Age Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Amery, Wisconsin.
- Location
- 220 Scholl Ct, Amery, Wisconsin 54001
- CMS Provider Number
- 525507
- Inspections on file
- 22
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Golden Age Manor during CMS and state inspections, most recent first.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility did not have a qualified director of food and nutrition services, as the Dietary Manager's certification did not meet the required standards, and there was no full-time, in-house dietician. The dietician was fully remote, and the facility could not provide evidence of compliance monitoring in the kitchen, potentially affecting all residents.
Surveyors found that opened and prepared foods in the kitchen were not labeled or dated as required, and a staff member responsible for checking food temperatures failed to allow the thermometer probe to air dry after cleaning with isopropyl alcohol before use. These lapses in food safety practices had the potential to affect all residents.
The facility lacked an effective infection prevention and control program, with outdated water management policies, incomplete infection surveillance during outbreaks, and inconsistent hand hygiene practices by staff. Residents with indwelling devices were not always placed on enhanced barrier precautions, and staff failed to follow proper glove use and hand hygiene protocols during personal care, as acknowledged by supervisors.
The facility did not implement an effective antibiotic stewardship program, as required by its own policy, resulting in incomplete documentation of infection surveillance and a lack of standardized monitoring for antibiotic use. The Infection Preventionist relied on delayed pharmacy reports and did not use established criteria, such as McGeer's or Loeb's, to assess the appropriateness of antibiotic therapy.
Several residents reported missing clothing and personal items, but the facility did not consistently document grievances, investigate, or resolve these concerns. Staff interviews and observations revealed a lack of a clear process for labeling and tracking residents' clothing, resulting in many unlabeled items and unresolved losses. The Director of Nursing acknowledged the ongoing issue, and residents often had to keep their own records to track belongings.
Facility staff did not ensure safe, appropriate pain management for several residents with chronic and acute pain, failing to conduct consistent pain assessments, develop individualized pain care plans, or document the effectiveness of pain interventions. Residents with complex medical needs, including those on opioids and palliative care, experienced unmanaged pain, missed medication doses, and lacked monitoring for side effects, with staff often relying on residents to request pain relief rather than proactively assessing and addressing pain.
An LPN left a medication cart in the hallway with the computer screen displaying residents' medical records unattended on multiple occasions while administering medications. This resulted in protected health information being visible to other staff passing by, in violation of facility policy requiring PHI confidentiality.
Two residents with significant mobility limitations did not consistently receive passive range of motion (PROM) exercises as ordered in their care plans. Documentation showed missed or insufficient PROM sessions, and staff interviews revealed that exercises were not routinely performed or reviewed for appropriateness. The lack of regular assessment and monitoring contributed to the ongoing deficiency in restorative care.
A resident with allergic rhinitis received a nasal spray medication from an LPN, who failed to document which nostril was used as required by facility policy. The LPN stated that staff no longer record the site of administration, and the DON was unaware this documentation was not occurring.
Three residents were found to be receiving unnecessary medications, including sleep aids and a prophylactic antibiotic, without adequate clinical indication, assessment, or individualized care planning. Staff did not monitor or document sleep patterns, and there was no evidence of non-pharmacological interventions or rationale for continued medication use, contrary to facility policy.
A resident with multiple chronic conditions was not documented as having been screened or offered the 2024-2025 COVID-19 vaccine. The facility's records lacked evidence of education, consent, or declination for the current vaccination year, and the only immunization policy provided did not address COVID-19. The Infection Preventionist stated the resident was not approached again because they had declined the vaccine the previous year.
Two residents did not have comprehensive care plans developed to address their specific medical and nursing needs. One resident receiving diuretics for edema and chronic kidney disease lacked a care plan for monitoring adverse reactions, while another resident on hospice care did not have a hospice or end-of-life care plan in place. These deficiencies were identified through observation, interviews, and record review.
A resident with Alzheimer's disease and anxiety disorder experienced a marked increase in aggressive and disruptive behaviors, including altercations with other residents. Despite multiple documented incidents and staff interventions, the care plan was not updated to reflect these changes or the new care approaches being provided, such as 1:1 supervision and medication adjustments.
A resident was placed in a private room measuring only 96.5 square feet, which is below the required 100 square feet for single occupancy. The facility administrator acknowledged the deficiency, noting that the room is used for ambulatory residents after informing them and their POA of the size difference. The resident, who has multiple medical conditions and severe cognitive impairment, reported being comfortable in the room.
A facility failed to provide adequate supervision during resident transfers with a Hoyer lift, as a CNA was left alone to transfer three residents due to a staffing shortage. The CNA proceeded with the transfers despite knowing the risk, as another CNA had to leave for a family emergency. The NHA and DON were not informed of the shortage until days later and confirmed that their policy requires two staff members for such transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Unqualified Food and Nutrition Services Director and Lack of Dietician Oversight
Penalty
Summary
The facility failed to designate a director of food and nutrition services who met the minimum qualification requirements for the position. During a kitchen tour, the Dietary Manager (DM) presented certifications, including a Food Protection Manager certificate accredited by ANSI-CFP, but this did not meet the requirements for a Certified Dietary Manager. The facility did not have a full-time, in-house dietician; instead, the dietician was fully remote, and no evidence was provided to show that the remote dietician was monitoring compliance in the kitchen. The Nursing Home Administrator confirmed the absence of an in-house dietician and was unable to provide documentation of oversight or compliance monitoring by the remote dietician. This deficiency potentially affected all 60 residents in the facility.
Improper Food Storage and Unsafe Temperature Probe Practices Identified
Penalty
Summary
Surveyors observed that the facility failed to ensure proper food storage and handling practices in accordance with professional standards. During a kitchen tour, several opened food items in the walk-in cooler, including sliced tomatoes, repackaged sour cream, shredded cheese, salads, and pre-poured juice, were found to be covered but not labeled or dated with an opened or use-by date. The Dietary Manager confirmed that the expectation was for all opened or prepared foods to be labeled and dated, but this was not done, resulting in the disposal of potentially hazardous foods. Additionally, during food temperature checks, the Head of the kitchen was seen cleaning the thermometer probe with isopropyl alcohol wipes and immediately inserting it into food items without allowing it to air dry as required by FDA Food Code. The Head of the kitchen admitted to not being aware of the need to let the probe air dry between uses and was unsure of when she was last trained on this procedure. These practices were observed to have the potential to affect all residents in the facility.
Infection Control Program Deficiencies and Lapses in Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in policy implementation, surveillance, and staff practices. The water management policy was outdated and lacked specific control measures to prevent the spread of Legionella, particularly in unoccupied rooms and a vacant wing. The infection preventionist and other staff acknowledged that flushing of water lines in these areas was not formally documented in the policy, and there was no clear process for addressing water stagnation. Infection surveillance logs for outbreaks of influenza and COVID-19 were incomplete, missing critical information such as symptom onset dates, staff last worked dates, test types and results, treatment parameters, isolation details, and resolution dates. The facility did not track or document the implementation of isolation precautions, PPE usage, or staff education during outbreaks. Additionally, the process for managing sick staff was informal, with untrained personnel making decisions about staff illness and return-to-work, and no formal tracking of staff testing or work locations during outbreaks. Direct care observations revealed that staff did not consistently follow hand hygiene protocols during personal care activities. In one instance, a CNA failed to perform hand hygiene after removing soiled gloves and before re-gloving while providing care to a resident on enhanced barrier precautions. Another resident with an indwelling catheter did not have enhanced barrier precautions initiated as required by facility policy. In a separate case, a CNA continued care after soiling gloves, wiped them clean instead of changing them, and did not perform hand hygiene after glove removal. These lapses were acknowledged by staff and supervisors as contrary to facility policy and training.
Failure to Monitor and Document Antibiotic Use in Infection Control Program
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP) that included an Antibiotic Stewardship Program with protocols and a system to monitor antibiotic use. The facility's policy assigned the Infection Preventionist (IP) responsibility for monitoring, investigating, and controlling infections, as well as tracking infection incidence rates and reviewing this information quarterly with the interdisciplinary team and medical director. However, review of infection surveillance logs revealed missing documentation, including incomplete records of symptom onset dates, culture/test types and results, antibiotic treatment parameters (such as antibiotic selection and start/stop dates), and infection resolution dates and times. During an interview, the Infection Preventionist (RN) stated that antibiotic tracking was based on monthly reports received from an external pharmacy provider, which were reviewed approximately two weeks after antibiotics were started. The RN was unable to describe a process for tracking infections, monitoring antibiotic selection, or ensuring appropriate antibiotic use, and deferred these decisions to the prescribing physician. The RN also confirmed that no standardized criteria, such as McGeer's or Loeb's, were being used to determine the need for antibiotics or to monitor their appropriateness, and was unfamiliar with these guidelines until referenced by the surveyor.
Failure to Address and Resolve Resident Grievances Regarding Missing Laundry Items
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal and did not establish or follow an effective grievance policy regarding missing laundry items. Multiple residents reported missing clothing and personal items to staff, but the facility did not consistently document these grievances, conduct thorough investigations, or provide resolutions. Resident council meeting minutes and interviews revealed that several residents experienced ongoing issues with missing clothing, with some items never being found or replaced, and residents often ceased pursuing the matter after initial reports to staff. Surveyor observations and interviews with staff, including the Laundry Director and Nursing Home Administrator, revealed a lack of a clear and consistently implemented process for labeling residents' clothing. Many clothing items remained unlabeled, as evidenced by approximately 80 pieces of clothing on an unlabeled cart in the laundry area. Staff acknowledged that the process for labeling and tracking clothing was not well defined or enforced, and that staff training on this process could not be substantiated with documentation. The facility's grievance logs showed some instances where missing items were found and returned, but other cases were not documented or resolved, and there was no evidence of prompt or systematic efforts to address the broader issue. Interviews with residents and staff further highlighted the facility's inadequate response to grievances about missing laundry. Residents described having to keep personal records to track their belongings, and staff often relied on informal methods or other departments to search for missing items. The Director of Nursing acknowledged the ongoing problem with missing laundry due to improper labeling and confirmed that the facility had not resolved this concern. The lack of a clear, documented process and failure to address residents' grievances led to unresolved losses of personal property for several residents.
Failure to Provide Comprehensive Pain Management and Assessment
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for multiple residents requiring such services, as evidenced by inadequate pain assessments, lack of comprehensive and individualized pain care plans, and insufficient monitoring and documentation of pain interventions. For several residents with chronic and acute pain, including those with complex medical histories such as palliative care, cancer, chronic pain syndromes, and neuropathy, the facility did not consistently assess pain using standardized tools, document pain characteristics, or follow up on the effectiveness of pain medications. In some cases, pain levels were not recorded before or after medication administration, and non-pharmacological interventions were either not offered, not documented, or not included in care plans. One resident with chronic pain and a history of palliative care experienced repeated episodes of severe pain, including a period when a scheduled Fentanyl patch was not administered as ordered, resulting in increased pain and the need for additional PRN opioid medications. Despite these events, there was no comprehensive pain care plan in place, and pain assessments were not consistently performed or documented during periods of increased pain. Staff interviews confirmed that pain management was largely reactive, with staff waiting for residents to request medication and not routinely assessing or documenting pain levels or the effectiveness of interventions. Other residents with chronic pain, cancer, or neuropathy also lacked individualized pain care plans, and their records showed inconsistent or absent documentation of pain assessments, non-pharmacological interventions, and monitoring for opioid side effects such as constipation and sedation. The facility's own policies required comprehensive, multidisciplinary pain management, including regular assessments, care planning, and monitoring for adverse effects, but these standards were not met for the residents reviewed. Staff and leadership interviews acknowledged these deficiencies, noting that pain assessments and care planning were not consistently completed or documented as required.
Failure to Safeguard Resident Medical Record Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of resident medical records for three out of five sampled and supplemental residents. Facility policy requires that protected health information (PHI) in any form remain confidential and that care be taken to ensure privacy when handling such information. Despite this, observations revealed that an LPN repeatedly left a medication cart in the hallway with the computer screen displaying residents' medical records unattended. This occurred multiple times while the LPN was administering medications to different residents, leaving their PHI visible to staff passing by in the hallway. Specific incidents included the LPN leaving the computer screen open with individual residents' medical records displayed while entering residents' rooms to administer medications. On several occasions, other staff members walked past the unattended cart with the open screen. The Nursing Home Administrator confirmed that employees are expected to safeguard PHI and close or lock computer screens when left unattended, but this expectation was not met during the observed events.
Failure to Provide and Assess Restorative ROM Services for Residents with Limited Mobility
Penalty
Summary
The facility failed to ensure that two residents with limited mobility received appropriate restorative services and assistance to maintain or improve their range of motion (ROM) as ordered. For one resident with severe cognitive impairment and multiple diagnoses including Alzheimer's disease, hemiplegia, and muscle weakness, the care plan required daily passive range of motion (PROM) exercises for both upper and lower extremities. However, restorative nursing logs showed inconsistent and often minimal completion of PROM, with several days where exercises were not performed at all. Staff interviews confirmed that ROM was only completed during morning care, and there was no evidence of regular review or assessment of the program's appropriateness. Another resident with multiple sclerosis, paraplegia, and a history of contractures had a care plan for a daily stretching program at bedtime. Documentation revealed that PROM was inconsistently performed, with several days missed and no prior tracking available before a certain date. The resident reported that ROM exercises were only done if specifically requested, and staff interviews indicated a lack of program review and assessment. The registered nurse acknowledged that the absence of regular assessments contributed to the failure to identify and address these deficiencies.
Failure to Document Site of Nasal Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with its own medication administration policy, specifically regarding the documentation of the route and site of administration for inhaled medication. A resident with a diagnosis of allergic rhinitis had a physician's order for calcitonin nasal spray to be administered in alternating nostrils daily. During a medication pass, an LPN was observed administering the nasal spray into the resident's right nostril and documenting the administration, but did not record which nostril was used. Upon interview, the LPN stated that staff previously documented the nostril used but had stopped doing so, relying instead on memory. The Director of Nursing confirmed that staff are expected to document the site of administration and was unaware that this was not being done.
Failure to Ensure Drug Regimens Are Free from Unnecessary Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure residents' drug regimens were free from unnecessary medications for three out of five residents reviewed. Specifically, residents were prescribed sleep medications such as melatonin and trazodone without adequate clinical indications, assessments, or care plans addressing sleep management. There was no documentation of sleep assessments, monitoring of sleep patterns, or tracking of sleep quality to justify the continued use of these medications. The care plans for these residents did not include individualized interventions or non-pharmacological approaches to promote sleep, as required by facility policy. One resident was also found to be receiving a daily antibiotic for urinary tract infection (UTI) prevention without documented rationale or evidence supporting the need for prophylactic antibiotic use. The infection preventionist and nursing staff were unable to provide criteria or justification for the ongoing antibiotic therapy, and there was no documentation of recurrent UTIs or physician rationale for this regimen. Staff interviews revealed a lack of understanding regarding the appropriateness of the medication orders and an absence of oversight or challenge to the prescriber's decisions. The facility's policy requires comprehensive assessment and individualized care planning for behavioral and psychosocial symptoms, including sleep disturbances. However, the survey found that these processes were not followed. There was no evidence of behavioral assessments, cause identification, or targeted interventions for the affected residents. Staff interviews confirmed that sleep was not routinely monitored or documented, and care plans did not address sleep issues or include non-pharmacological interventions, resulting in the continued use of unnecessary medications.
Failure to Document COVID-19 Vaccination Screening and Offer
Penalty
Summary
The facility failed to maintain documentation of screening, education, and offering of the current COVID-19 vaccination for one of five residents reviewed. Specifically, the electronic medical record for a resident with multiple diagnoses, including Alzheimer's disease, chronic kidney disease, and dementia, did not contain any documentation indicating that the resident had been screened or offered the 2024-2025 COVID-19 immunization. When the surveyor requested documentation, none was available for this resident, and the only policy provided by the facility addressed influenza and pneumococcal vaccinations, with no reference to COVID-19 vaccination procedures. During interviews, the Infection Preventionist (IP) stated that residents and staff are offered immunizations annually, and that education and consent are obtained either directly from the resident or through their Power of Attorney. However, the IP was unable to provide a COVID-19 consent or declination form for the resident in question, explaining that the resident had declined the vaccine in the previous year and was therefore not approached again for the current vaccination year. No further documentation was found after checking with the pharmacy.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing the medical and nursing needs of two residents. For one resident with diagnoses including type 2 diabetes mellitus, chronic kidney disease stage 3b, and edema, there was no care plan in place to monitor for adverse reactions or efficacy related to the administration of diuretic medications, despite the resident receiving furosemide and exhibiting significant edema and mobility difficulties. The absence of a care plan was confirmed through record review and interviews, with the Director of Nursing acknowledging the oversight. For another resident with multiple complex diagnoses, including Alzheimer's disease, dementia, and severe cognitive impairment, who was receiving hospice services, the facility did not develop a hospice or end-of-life care plan. This was confirmed through review of the resident's care plans and direct inquiry with the Nursing Home Administrator, who indicated that no hospice care plan had been created. These deficiencies were identified through observation, interview, and record review.
Failure to Update Care Plan Following Escalation of Resident Behaviors
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect recent changes in behavior and to provide appropriate direction to staff. The resident, who has Alzheimer's disease with late onset, dementia, and an anxiety disorder, exhibited a significant increase in behavioral issues, including physical and verbal aggression, spitting, yelling, throwing objects, and involvement in altercations with other residents. Despite these documented incidents and changes in the resident's condition, the care plan was not updated to include new interventions or reflect the care being provided, such as the initiation of 1:1 supervision and medication adjustments. Documentation reviewed by the surveyor showed multiple behavioral incidents over several days, with staff and LPNs intervening and reporting the events. However, the care plan remained unchanged from its original version, and new interventions were not formally documented until after the survey process began. The facility's own policy requires ongoing assessment and timely revision of care plans as residents' conditions change, but this was not followed in the case of this resident.
Single Resident Room Below Minimum Size Requirement
Penalty
Summary
The facility failed to ensure that a single resident room met the required minimum size of 100 square feet, as specified in the State Operations Manual, Appendix PP- Guidance to Surveyors for Long Term Care Facilities. During the survey, it was observed that one resident was occupying a room measuring only 96.5 square feet. The Nursing Home Administrator confirmed that the room was smaller than the regulatory requirement and stated that no remodeling had been done to address the deficiency. The administrator also indicated that the facility has limited private rooms and reviews the use of this undersized room annually, placing only smaller, ambulatory residents in it after informing them and their Power of Attorney about the room size. The resident occupying the room was admitted with multiple diagnoses, including atrial fibrillation, anxiety, depression, malnutrition, an unspecified mental disorder, and attention deficit hyperactivity disorder. The resident was assessed as severely cognitively impaired but able to make herself understood and ambulate independently. During an interview, the resident expressed satisfaction with the room, describing it as comfortable and appreciating features such as a large window. The surveyor attempted to contact the resident's Power of Attorney but did not receive a response.
Inadequate Supervision During Resident Transfers
Penalty
Summary
The facility failed to ensure adequate supervision during resident transfers with a mechanical lift, specifically a Hoyer lift, which posed a risk of falling. This deficiency was identified for three residents. On a specific day, a Certified Nurse Assistant (CNA) was left alone to transfer these residents due to a staffing shortage caused by another CNA leaving for a family emergency. The CNA acknowledged the risk of transferring residents alone but felt compelled to proceed due to the lack of available staff. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were not informed of the staffing shortage on the day it occurred and only became aware of the situation days later. Both the NHA and DON confirmed that their policy requires two staff members to operate a Hoyer lift, and they were unaware that the CNA had to perform the transfers alone.
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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