Heritage Lakeside
Inspection history, citations, penalties and survey trends for this long-term care facility in Rice Lake, Wisconsin.
- Location
- 1016 Lakeshore Dr, Rice Lake, Wisconsin 54868
- CMS Provider Number
- 525654
- Inspections on file
- 40
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Heritage Lakeside during CMS and state inspections, most recent first.
Failure to Assess and Notify Provider for Respiratory Decline: A resident with OSA, DVT history, and multiple chronic conditions developed SOB, low O2 sats, and continuous daytime CPAP use, but nursing did not complete ordered respiratory assessments or notify the provider when the change in condition began. Staff treated the resident with oxygen and monitored her symptoms, while the resident continued to report that she could not breathe without CPAP. The resident was later found to have a significant PE and DVT and required hospital transfer and thrombectomy.
Unsanitary food handling and service practices were observed in the kitchen and dining areas. Staff entered food prep areas and handled food, clean dishes, and storage containers without hand hygiene, used the same gloves across dirty and clean tasks, and a dietary aide’s scrubs were contaminated by dirty dish water before he later delivered snacks to residents. Food was found open and unlabeled, uncovered, and stored with a scoop in a bin, while leftover gravy was left uncovered to cool and temperatures were not consistently taken or documented for all menu items during service.
A resident prescribed Escitalopram Oxalate for depression did not have documented informed consent in the record when reviewed by the surveyor. The DON could not initially provide the consent, and the chart later showed a consent scanned after the surveyor’s inquiry; progress notes indicated verbal consent was obtained from the POA and that signature forms were left at the front desk. The Regional DON stated the facility’s usual process is to complete consent when the psychotropic is started, but this resident’s consent was somehow missing.
Failure to Protect Resident from Verbal Abuse: A resident with intact cognition and a history of amputation-related care and anxiety reported that an RN yelled at him, blocked his wheelchair, and grabbed his arm while enforcing masking and room restriction after the resident’s girlfriend may have been ill. The resident said he felt traumatized and later complained of pain, while the RN documented that she only stopped the wheelchair and that the resident was verbally abusive toward her; staff interviews reflected conflicting accounts of the encounter.
Failure to Immediately Report Alleged Abuse: A resident with intact cognition and a history including lower-extremity amputation and anxiety reported that an RN yelled at him, blocked his wheelchair, and grabbed his arm while enforcing mask use and room restriction after a possible exposure. The RN documented stopping the wheelchair and denied physical contact beyond touching the chair, but the allegation was only texted to the NM and was not immediately escalated to the NHA or reported to the state agency as required by policy.
Failure to Protect Resident During Abuse Investigation: A resident with intact cognition and a history of amputation-related care alleged that an RN yelled at him, restricted his movement, and grabbed his arm. Although the RN acknowledged the resident was accusing her of grabbing his arm, she continued to care for him while the allegation was pending, and the nurse manager did not immediately remove her from resident care.
Missing transfer notices, bed-hold documentation, and ombudsman notification: The facility did not provide complete transfer paperwork for several residents sent to the hospital. Surveyors found transfer notices that lacked the specific reason for transfer, and for two residents there were no bed-hold forms or documentation that the ombudsman was notified. The residents had significant medical conditions, including CKD, DM2, COPD, CHF, hemiplegia, and respiratory failure.
Failure to Reposition and Document Refusals for Resident With Coccyx Pressure Injury: A resident with cognitive impairment, weakness, malnutrition, and a stage 3 coccyx/sacral pressure injury was ordered to be repositioned every 2 hours, but the record lacked documentation of ongoing repositioning or refusals. Staff stated the resident often refused to change position and preferred to lie on the back, yet no alternative offloading options were documented. Surveyors observed the resident supine without coccyx offloading, and the wound progressed, requiring ED transfer, hospital admission for fever and wound evaluation, and surgical debridement.
An infection control deficiency occurred when an LPN and RN did not perform hand hygiene before medication administration, before entering or leaving resident rooms, and before glove use while caring for multiple residents. Staff also failed to wipe down a blood pressure cuff and machine between residents, and the same cuff was later used on another resident. The DON stated hand hygiene should occur before and after medication preparation, room entry and exit, and glove use, and that blood pressure cuffs should be wiped between residents.
A resident with moderate cognitive impairment was reported by their responsible party to be missing a wallet containing identification cards. The facility delayed reporting the allegation of misappropriation to the state survey agency and did not notify law enforcement, contrary to policy requirements. Staff interviews and documentation confirmed the reporting failures.
A resident with moderate cognitive impairment was reported missing a wallet containing identification cards. The facility's investigation did not include interviews with staff who cared for the resident, despite policy requirements. Multiple staff members later confirmed they were not interviewed or aware of the missing wallet, resulting in an incomplete investigation.
A resident with a history of stroke and obesity experienced a fall from a wheelchair during van transport, but no fall incident report was completed and no interventions were added to the care plan. The care plan also failed to document the resident's preference for multiple wheelchair supports and did not include a physician's order for a CAM boot, despite these being in use and observed by staff.
A resident with right-sided weakness and morbid obesity was transported in a wheelchair while sitting on multiple non-standard items, which were not removed prior to transport. During the ride, sudden braking caused the resident to slide under the safety belts and fall, resulting in a right ankle fracture. The use of these additional items in the wheelchair contributed to the accident, and emergency services were required to assist.
A facility failed to ensure that nurses and nurse aides had documented competencies to care for all residents, as evidenced by an LPN performing a blood draw from a resident's foot without proper training or policy guidance. Multiple staff lacked documented training or competency evaluations for venipuncture, and there was no system in place to assess or document these skills among newly hired nursing staff.
Two residents receiving anticoagulant therapy did not have care plans addressing their medication use or risk for bleeding, despite relevant diagnoses and changes in condition. Staff interviews revealed inconsistent processes for updating and communicating care plans, and the facility did not follow its own policies requiring comprehensive, risk-based care planning.
Staff failed to implement effective interventions to prevent a resident with dementia and a history of inappropriate nudity from exposing his genital area to two other cognitively impaired residents. Despite staff awareness and repeated reports that the use of a blanket was ineffective, no new measures were put in place, resulting in continued exposure incidents.
The facility did not comply with food safety standards by failing to label and date perishable items in the refrigerator. Observations revealed unlabeled and outdated food items, including cherry jam, chopped onions, milk, V8 juice, and pulled pork. Interviews with the interim Kitchen Supervisor and Registered Dietitian confirmed the oversight and acknowledged the need for proper labeling and disposal according to policy.
The facility failed to properly store and label insulin, affecting several residents. Insulin pens and a vial were found in a refrigerator below the required temperature range, with incomplete temperature logs. Additionally, a resident's insulin pen label did not match the physician's orders, posing a risk of incorrect administration. The DON acknowledged the issues and the need for adherence to facility policies.
A resident with Parkinson's disease was unable to access the sink in his room due to its location, preventing him from performing personal hygiene tasks. Despite being aware of the issue, staff did not provide necessary assistance, and the DON was unaware of the problem.
A resident with Parkinson's and dementia did not receive necessary hand hygiene assistance after toileting, despite facility policy emphasizing its importance. Observations showed staff failed to offer hand hygiene, and interviews revealed the resident's inability to access the sink due to space constraints. Staff acknowledged the oversight, and the DON highlighted expectations for assisting residents with hand hygiene.
A resident with a foot wound did not receive the necessary treatment upon admission to the facility. The wound was identified during an initial skin evaluation, but an order to apply a mepilex was not entered into the system, resulting in a lack of treatment. The Director of Nursing acknowledged the oversight, and the wound remained untreated during the resident's stay.
The facility failed to ensure adequate supervision and use of safety devices for two residents. One resident with Parkinson's disease was transferred without a gait belt, contrary to policy, and left unsupervised during personal care. Another resident with dementia and a history of falls did not have their care plan updated with new interventions after a fall, despite being at moderate fall risk. These deficiencies highlight lapses in adhering to care plans and policies, compromising resident safety.
A facility failed to provide appropriate treatment for a resident with an indwelling Foley catheter by not ensuring catheter changes were based on clinical indications. The resident's catheter was changed monthly without documented medical justification, contrary to CDC guidelines. The facility's policy lacked standards for catheter removal frequency, and the Director of Nursing could not provide a physician's justification for the practice.
A facility failed to conduct lung assessments for a resident with COPD during nebulizer treatments, as required by standard nursing care. The RN did not perform lung assessments before or after the treatment, and the DON confirmed the absence of a policy mandating such assessments unless ordered by a doctor. The resident reported never having lung assessments or being instructed on post-treatment care, highlighting a gap in adherence to professional standards.
A facility failed to provide trauma-informed and culturally competent care for a resident with PTSD and major depression. The resident's care plan lacked comprehensive assessment and documentation of trauma history, triggers, and interventions. Staff interviews revealed a lack of awareness and follow-through on the resident's trauma-related needs, resulting in a deficiency in care.
A resident lost their partial upper denture, and the facility lacked a policy to address such incidents, failing to provide timely dental care. Despite the resident's intact cognitive status and communication abilities, the facility did not replace the dentures or offer dental services, citing a lack of responsibility unless negligence was proven. The resident's grievance was documented, but no follow-up actions were taken to assist in obtaining new dentures.
A long-term care facility failed to maintain an effective infection prevention and control program, as observed in care for two residents. A CNA did not perform hand hygiene between tasks, and an RN failed to disinfect reusable medical equipment after use. Additionally, a resident requiring enhanced barrier precautions did not have the necessary signage or PPE cart outside their room, contrary to facility policy.
The facility's admission packet failed to ensure residents were not required to waive liability for personal property losses. The Resident Handbook states the facility is not responsible for replacing misplaced items unless linked to staff negligence. This policy potentially affects all 33 residents.
The facility failed to provide written notification of transfer or discharge to four residents and their representatives, as well as the ombudsman, during hospitalizations. Residents with various medical conditions, including myocardial infarction, respiratory failure, and Parkinson's disease, were transferred to hospitals without receiving the required written notices. Interviews with staff revealed confusion and inconsistency in the notification process.
The facility failed to correctly post daily nurse staffing information, omitting the resident census and facility name on several occasions. A review of 30 postings showed 17 lacked the resident census, and six were missing the facility name. The DON acknowledged the need for a better system to ensure compliance.
A resident's family reported an allegation of abuse involving a CNA bending the resident's fingers to cause pain, resulting in bruising. The facility failed to report this incident to the State Agency as required, despite the resident's moderate cognitive impairment and need for assistance with ADLs. The facility's use of an incorrect flowchart led to the failure in reporting.
A resident with a history of Alzheimer's and atrial fibrillation experienced a change in condition that was not properly assessed by staff, leading to a stroke and subsequent hospice care. Despite signs of a stroke, comprehensive neurological assessments were not conducted, and the resident's condition was not promptly reported to a physician. The resident was not transferred to the emergency room until several hours later, resulting in serious harm.
The facility failed to provide adequate hydration and nutrition for three residents, leading to severe dehydration and malnutrition. One resident, with multiple health issues, was not properly assessed for hydration needs, resulting in hospitalization and death. Another resident, post-stroke, lacked an updated care plan and monitoring of intake/output, despite family concerns. A third resident, at high risk for dehydration, had no interventions in place, leaving them vulnerable to harm.
Two residents in an LTC facility experienced inadequate pressure ulcer care, leading to deficiencies in treatment and documentation. One resident developed a deep tissue injury on the heel due to insufficient repositioning and lack of protective measures, despite being at high risk. Another resident's stage 4 pressure injury on the lumbar spine was not properly documented, leading to a delay in identifying an infection. The facility failed to adhere to guidelines for pressure injury prevention and treatment, resulting in harm to the residents.
The facility did not ensure two CNAs received the required 12 hours of annual in-service training, including communication, behavioral health, and dementia care. Despite multiple requests, the facility could not provide documentation of completed training, and the NHA acknowledged the absence of a process to ensure compliance.
A Dietary Aide failed to follow proper hand hygiene protocols during meal service, handling meal tickets and then directly touching food items without changing gloves. This affected several residents, as the aide did not adhere to the facility's policy prohibiting bare hand contact with food and requiring glove changes between tasks.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to hygiene and PPE protocols. Instances included improper sanitization of equipment, lack of hand hygiene during care, and failure to wear required PPE for residents on transmission-based precautions. These lapses were observed across multiple staff members and residents, indicating systemic issues.
A resident with multiple health conditions experienced low blood pressure on several occasions, but the facility failed to notify the physician as required by policy. Despite orders to monitor blood pressure every shift and report concerns, the physician was only informed twice out of fourteen instances. Interviews confirmed the expectation for immediate notification of irregularities, which was not met.
A resident with Alzheimer's and impaired cognition was not provided privacy during personal care in an LTC facility. Surveyors observed staff leaving window blinds open and not using privacy curtains, resulting in the resident's exposure to the hallway. The resident's care plan was outdated, and staff failed to cover the resident during care activities, leading to concerns from family and staff.
A resident with Alzheimer's and other health issues was neglected in their care, with observations of poor hygiene, unchanged sheets, and inadequate personal care. Despite being dependent on staff, the resident's care plan was outdated, and staff failed to provide necessary grooming and hygiene, as confirmed by family and staff interviews.
A resident with an indwelling Foley catheter did not receive proper care and assessment due to the absence of a physician order and outdated care plan. Observations revealed the catheter bag on the floor with discolored urine and sediment, while staff failed to communicate or address the issues. The resident showed signs of pain and discomfort, but staff did not assess for complications, leading to a deficiency in care.
An LPN failed to prime insulin pens before administering insulin to two residents, contrary to the facility's policy and manufacturer's instructions. The LPN incorrectly believed priming was unnecessary, which was confirmed as incorrect by the DON.
A resident's insulin pens were found unattended and improperly stored on a bedside table, with one pen expired and lacking an open date. The resident, who wished to self-administer medications, kept the pens accessible due to difficulty reaching the lock box. The DON was unaware of this practice and acknowledged the need for proper storage.
A resident at high risk for pressure injuries developed an unstageable pressure injury on the right foot and a stage II injury on the right buttock due to the facility's failure to conduct weekly assessments and implement preventative measures. The care plan lacked specific interventions for skin breakdown, and observations showed the resident's feet were not properly elevated. Staff interviews revealed a lack of responsibility for wound assessments, leading to actual harm.
A CNA at a facility flushed a resident's PEG/G-tube, an action outside her scope of practice, which was identified as potential abuse or neglect. The incident was discovered but not reported to the state agency until much later, violating the required reporting timeline. The DON, new to her role, was unfamiliar with the reporting process, leading to the delay.
A CNA inappropriately flushed a resident's feeding tube, an action outside her scope of practice, leading to an inadequate investigation by the facility. The incident was reported by a TMA, but the facility's investigation lacked comprehensive staff and resident interviews, and there was no evidence of post-incident education on CNA scope of practice.
A CNA improperly flushed a resident's feeding tube, which was outside her scope of practice. The resident required tube feeding due to a swallowing problem, with specific orders for flushing. The CNA acted without proper qualification, claiming she was instructed by an RN, who denied this. The facility failed to provide post-incident education on CNA scope of practice.
A facility failed to provide necessary treatment and services for two residents with non-pressure injuries. One resident, with conditions including diabetes and renal disease, developed multiple facility-acquired non-pressure injuries that were not accurately documented or treated as per physician orders. Interviews confirmed that staff did not consistently check the resident's feet and heels, leading to a lack of timely intervention.
The facility failed to supervise two residents during meals, despite care plans indicating the need for supervision due to swallowing difficulties. Both residents were observed eating without staff present, which was confirmed by a CNA and the DON, highlighting a procedural oversight in meal supervision.
A facility failed to provide adequate pain management for a hospice resident with multiple serious health conditions. Despite a care plan requiring medication administration and monitoring, the facility did not consistently administer as-needed medications or document their effectiveness. The resident experienced prolonged periods of high pain without appropriate intervention, and staff reported delays in receiving medications from the pharmacy, contributing to inadequate pain management.
Failure to Assess and Escalate Respiratory Change in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who had multiple chronic conditions, including obstructive sleep apnea, morbid obesity, cardiomegaly, atherosclerotic heart disease, hypertension, stage 3 kidney disease, type 2 diabetes, prior stroke with hemiplegia, dysphagia, and a history of DVT while on anticoagulation. The resident’s care plan included monitoring for shortness of breath, cough, and other respiratory changes, and a physician order required a respiratory assessment in the evening. After the resident began reporting shortness of breath and difficulty breathing, staff documented low oxygen saturation and applied oxygen at 2L nasal cannula, but the provider was not notified at that time. The resident continued to have complaints of shortness of breath and began using CPAP continuously during the day, stating she could not breathe without it. The record showed missing respiratory assessments on multiple dates despite the physician order, and the facility did not complete comprehensive assessments after episodes of difficulty breathing. Staff notes also documented the resident refusing to get out of bed on several days, but the record did not show comprehensive assessments tied to those refusals. Interviews showed nursing staff believed standing oxygen orders were sufficient, and one nurse stated the resident’s ongoing anxiety and CPAP use were being monitored rather than escalated to the provider. The resident was later evaluated by the NP, who ordered a CTA of the chest because of concern for possible PE. Imaging then showed a significant PE, and the resident was transferred to the hospital, where she was diagnosed with PE and DVT and underwent pulmonary artery thrombectomy. Survey review also found that the provider was not notified on the initial change in condition, that respiratory assessments were not completed as ordered on several dates, and that the facility did not implement new care plan interventions in response to the resident’s worsening respiratory complaints.
Unsanitary food handling, storage, cooling, and service practices
Penalty
Summary
The facility failed to prepare and distribute food under sanitary conditions. During observations in the kitchen and food service areas, staff were seen handling food and food service items without hand hygiene when entering the kitchen, changing tasks, or before touching food and clean equipment. A dietary aide returned to the kitchen and handled juice trays without washing hands, another dietary aide handled beverages and temperatures without hand hygiene, and the dietary manager entered the kitchen and handled food and storage items without washing hands. A registered dietician later observed a dietary aide moving between dirty and clean tasks with the same gloves and instructed the aide to remove the gloves and wash hands. Food storage practices were also observed to be unsanitary. Open bags of noodles were found twisted shut without manufacturer labels, open dates, or use-by dates. A scoop was found in a flour bin. An open gallon of milk had no readable expiration date, and the dietary manager dated the cap while the surveyor was present. Two bottles of BBQ sauce and three bottles of syrup were undated, and peeled cucumbers were left uncovered in a stainless-steel bowl. The dietary manager stated that items are supposed to be labeled when received and when opened, and the registered dietician stated food should be stored in a clean, labeled container with a cover. Food cooling and temperature monitoring were not done as described in facility policy. Leftover gravy was placed in a food storage container and left uncovered, and staff stated they let foods sit out to cool without a temperature log and did not recheck once food was placed in the refrigerator. The dietary manager was uncertain about the cooling time frame when checking the gravy later, and the gravy remained in the cooler the next day before being discarded. During lunch service, temperatures were taken for some foods, but not for all items being served, including substitute meat and pureed items, and some temperatures were not recorded on the log. Staff also served food while some items were not at the documented required temperatures. In the dish room, a dietary aide sprayed dirty dishes and contaminated his scrubs with dirty water, then later delivered snacks to residents wearing the same contaminated scrubs without an apron or cover-up.
Missing Informed Consent for Psychotropic Medication
Penalty
Summary
The facility did not ensure that one resident, R6, had documentation showing that the resident and/or legal representative was informed in advance of the risks and benefits of a prescribed psychotropic medication. R6 was admitted with diagnoses including hypertensive chronic kidney disease, gangrene of the left leg, atherosclerosis of the arteries of the extremities, multiple fractured ribs, type 2 diabetes mellitus, acute pulmonary edema, major depressive disorder, and anxiety. R6 was prescribed Escitalopram Oxalate 5 mg daily for depression, but the medical record did not contain an informed consent for the medication when the surveyor reviewed the chart. During the survey, the DON was asked about the consent for Escitalopram Oxalate started on 02/19/26 and initially said she would look for it. She later provided monthly pharmacy reviews but could not provide the informed consent. The surveyor then found an informed consent completed and scanned into the record on 03/24/26. The resident’s progress notes stated that verbal consent was obtained from the POA for Escitalopram and that the POA was asked to stop in to sign the forms, which were left at the front desk. The Regional DON later stated that the DON usually completes informed consent the day the medication is started and sends it to medical records to scan, but R6’s consent was somehow missing.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by staff. The resident, who had diagnoses including orthopedic after care following surgical amputation of the lower extremity, acute osteomyelitis of the right tibia and fibula, mild cognitive impairment, and anxiety disorder, was assessed as cognitively intact with a BIMS score of 15/15 and required some assistance with activities of daily living. His care plan noted trauma-related symptoms and a pattern of misinterpreting staff communication, with interventions to keep staff interactions calm, clear, and supportive. The resident reported that an RN yelled at him, stood in front of his wheelchair to stop him from leaving, and grabbed his arm while he was trying to get away. He stated the interaction occurred after the RN told him he had to wear a mask and could not leave his room or use a shared bathroom because his girlfriend had symptoms of illness. The resident said he was upset, felt traumatized by the incident, and later reported pain in his left shoulder and arm area. He also told surveyors he had spoken with police and was concerned about retaliation. The RN documented that she had been told the resident’s girlfriend might have a virus, that she instructed the resident to wear a mask and stay in his room, and that the resident became verbally abusive toward her. In her note, she stated she stopped the resident’s wheelchair when he wheeled toward her and that there was no physical interaction other than touching the wheelchair. Facility staff gave differing accounts during interviews, including statements that the resident was upset and that both the resident and the nurse were yelling. The administrator, DON, and nurse manager described the resident as being told to mask and remain in his room, but the resident and his girlfriend reported that the nurse grabbed his arm and yelled at him, which formed the basis of the deficiency for failure to protect the resident from verbal abuse.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The facility did not ensure that an alleged abuse incident involving a resident was immediately reported to the NHA and then to the State Survey and Certification Agency. The facility policy titled Resident Safety Abuse Policy stated that the supervisor on duty shall immediately safeguard the resident and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, injuries of unknown source, and misappropriation of resident property to the facility administrator, and that the Administrator will notify the DON and/or others as appropriate. The policy also stated that alleged violations of abuse are to be reported immediately. The resident involved was admitted with diagnoses including orthopedic after care following surgical amputation of the lower extremity, acute osteomyelitis of the right tibia and fibula, mild cognitive impairment, and anxiety disorder. The most recent MDS assessment indicated the resident had no behaviors, required some assistance with ADLs, could independently use a wheelchair for mobility, and had a BIMS score of 15/15, indicating intact cognition. The resident reported that an RN yelled at him, told him he had to wear a mask and stay in his room, stood in front of his wheelchair to stop him from leaving, and grabbed his bad arm when he tried to get away. The RN documented that she attempted to speak with the resident about wearing a mask after learning his girlfriend possibly had a virus, that he yelled at her, and that she stopped his wheelchair to prevent it from running into her. The RN also documented that there was no physical interaction other than touching the wheelchair, while the resident and his girlfriend reported that she grabbed his bad arm. The nurse manager received a text from the RN stating the resident was claiming she grabbed his arm, but the nurse manager did not document an immediate investigation or notify the NHA at that time. The NHA stated she was not made aware of the allegation until Monday morning and that she would have reported the allegation to the state agency if she had been informed immediately.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility did not ensure protection from further potential abuse while an investigation was in progress for a resident who alleged verbal and physical abuse by an RN. The resident was admitted with diagnoses including orthopedic after care following surgical amputation of the lower extremity, acute osteomyelitis of the right tibia and fibula, mild cognitive impairment, and anxiety disorder. His most recent MDS assessment indicated no behaviors, some assistance with ADLs, independent wheelchair mobility, and a BIMS score of 15/15, indicating intact cognition. The facility policy stated the supervisor would ensure the resident was protected from further potential abuse, neglect, exploitation, or mistreatment during the investigation. The resident reported that the RN yelled at him, told him he had to wear a mask and remain in his room, blocked him from leaving, and grabbed his bad arm when he tried to leave. The RN documented that the resident said he did not want to talk to her and that she spoke with his girlfriend, who relayed that the resident said the RN grabbed his arm when a pop slid from his lap. The nurse manager received a text from the RN stating the resident was claiming she grabbed his arm, but the RN continued to work as the resident’s nurse after the allegation was made. The nurse manager stated she would investigate in the morning and had no documentation of the conversation, and the NHA stated the RN should have been immediately removed from working with residents while the allegation was investigated.
Missing transfer notices, bed-hold documentation, and ombudsman notification
Penalty
Summary
The facility did not ensure that residents and their representatives received complete transfer documentation, including the specific reason for transfer, bed-hold notice, and ombudsman notification for hospital transfers. Survey review found that for 3 residents reviewed for hospitalization, the transfer notices did not include a specific reason for the move to a higher level of care, and for 2 of those residents the facility did not provide bed-hold notices or documentation that the ombudsman was notified of the transfers. R6 was admitted with multiple diagnoses including hypertensive chronic kidney disease, gangrene of the left leg, atherosclerosis of the extremities, multiple rib fractures, type 2 diabetes mellitus, acute pulmonary edema, major depressive disorder, and anxiety. The record showed R6 was sent to the emergency room on 2 separate occasions. Survey review found transfer notices for those hospitalizations, but one notice was missing and the other stated only that an immediate transfer or discharge was required by urgent medical needs, without a specific reason. Surveyors also did not find bed-hold forms for either hospitalization or documentation that the ombudsman was notified. R46 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, obstructive sleep apnea, morbid obesity, cardiomegaly, atherosclerotic heart disease, hypertension, stage 3 kidney disease, type 2 diabetes mellitus, and a fracture of the lower end of the right femur. The resident was later re-admitted after extensive hospitalization with acute respiratory failure, embolism and thrombosis of arteries of the lower extremities, and acute embolism and thrombosis of a deep vein in the right lower extremity. Surveyors found one transfer notice that lacked a specific reason, did not find a transfer notice for another hospitalization, and did not find bed-hold forms or ombudsman notification documentation. R48, who had chronic respiratory failure, COPD, morbid obesity, type 2 diabetes, muscle weakness, hypertension, chronic systolic CHF, and chronic ischemic heart disease, was sent to the emergency room in respiratory distress, and the transfer notice reviewed for that hospitalization also did not include a specific reason for transfer.
Failure to Reposition and Document Refusals for Resident With Coccyx Pressure Injury
Penalty
Summary
The facility did not provide consistent repositioning or document refusals for a resident with a coccyx/sacral pressure injury. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, and protein-calorie malnutrition, had a BIMS score of 12/15, and made his or her own health care decisions. The care plan identified the resident as needing repositioning every 2 hours and included a stage 3 pressure ulcer to the coccyx, but the record did not include interventions for alternative offloading options when the resident refused repositioning, and surveyors could not find documentation of staff repositioning the resident in the medical record or paper CNA logs. Nursing notes showed the resident had an open coccyx area on 01/26/2026 and was placed on an offloading schedule every 2 hours. Subsequent documentation noted the resident continued refusing to get out of bed and offload the buttocks, and later declined getting out of bed for breakfast. A nursing note stated the resident was educated on the risk/benefit of mobility versus prolonged bedrest, but there was no documentation of refusals of repositioning after 02/04/2026. Surveyors observed the resident lying supine in bed without offloading of the coccyx area and also observed the resident sitting in a wheelchair with a pressure reducing mattress in place. Weekly wound assessments showed progression of the coccyx wound from 1.8 cm by 2.1 cm by 0.2 cm to 2.5 cm by 4.0 cm by 1.0 cm. The resident was transferred to the ED when the wound could not be debrided at the facility, and fever was discovered there, leading to hospital admission to rule out sepsis of the wound and receive IV antibiotics. The resident later underwent further debridement, had negative wound cultures, MRI findings compatible with an ulcer and sinus tract into subcutaneous fat, and was discharged back with new wound care orders. The discharge diagnosis included a stage 3 sacral ulcer with uncomplicated wound infection.
Failure to Perform Hand Hygiene and Clean Shared Equipment
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During observation, interview, and record review, surveyors found that LPN F, LPN G, and RN H did not perform hand hygiene before administering medications or before other resident care tasks, including blood sugar testing and glove use. These lapses were observed while the nurses were providing care to multiple residents, including R6, R34, R20, R19, and R2. On 3/23/26, LPN F was observed administering medications to R6 without hand hygiene before preparing the medications, before entering the room, or after leaving the medication cart. LPN F also handled a bottle of normal saline spray and handed it to R6 with contaminated hands. On the same day, RN H was observed preparing and administering medications to R34 after leaving the medication cart to retrieve a missing medication, without performing hand hygiene before returning to the cart, before entering the room, or before administering the medication. On 3/24/26, LPN G was observed preparing and administering medications to R19 without hand hygiene before preparation, leaving the cart, or entering the room, and later performed a blood sugar check on R20 without hand hygiene before putting on gloves. Also on 3/24/26, LPN G prepared medications for R2, used a crusher, and then put on gloves and administered medication through a g-tube without hand hygiene at the cart or before entering the room. In a separate observation, LPN F obtained blood pressure and pulse for R6 using a blood pressure cuff and machine, then left the cuff by the nurses’ station without wiping it down. RN H later used that same cuff with R33. The NHA stated there was no specific policy for wiping down blood pressure equipment, and the DON stated that blood pressure cuffs should be wiped down between residents and that glucometers are used on only one patient and are not shared.
Failure to Timely Report Alleged Misappropriation and Notify Law Enforcement
Penalty
Summary
The facility failed to submit an initial report of an allegation of misappropriation of a resident's property to the state survey agency within the required 24-hour timeframe and did not notify law enforcement as required. The incident involved a resident with a history of Alzheimer's disease, unspecified psychosis, and hallucinations, who had a moderately impaired cognitive status as indicated by a BIMS score of 12. The resident's responsible party reported via email that the resident's wallet and social security card were missing, and the resident had expressed concerns about people entering rooms and taking items. Facility records showed that a formal grievance was filed regarding the missing items, and the facility conducted interviews with the resident, who at times denied having the wallet at the facility and suggested another family member had possession of it. Despite these interviews and ongoing communication with the responsible party, the facility did not submit the required report to the state agency until several days after the initial allegation was made. Additionally, the facility's documentation and staff interviews confirmed that law enforcement was not contacted regarding the missing wallet and identification cards. The facility's Abuse Prevention Policy required immediate reporting of all alleged violations involving misappropriation of resident property to the state agency and law enforcement, depending on the circumstances. However, the administrator initially determined that the missing wallet, which did not contain money but did include identification cards, did not rise to the level of misappropriation and therefore did not report it promptly. The delay in reporting and failure to notify law enforcement were confirmed through interviews with facility staff and review of facility documentation.
Failure to Conduct Thorough Investigation of Alleged Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation involving a resident's missing wallet and identification cards. The resident, who had a history of Alzheimer's disease, unspecified psychosis, and hallucinations, was reported by a responsible party to be missing a wallet containing a state identification card and social security card. The resident's cognitive status was moderately impaired, as indicated by a BIMS score of 12. The responsible party notified the Social Services Director (SSD) via email, and a formal grievance was filed, with the facility offering to assist in replacing the missing items. Despite the facility's policy requiring timely and thorough investigations of all reports and allegations of abuse or misappropriation, the investigation did not include interviews or statements from staff who cared for the resident. The investigation consisted of interviewing the resident, searching for the wallet, and interviewing other residents, but omitted staff interviews. Multiple staff members, including LPNs, CNAs, and a Trained Medication Aide, confirmed during subsequent interviews that they had not been asked about the missing wallet and were unaware of the incident. Facility documentation, including the Monthly Grievance Log, Complaint/Grievance Report, and state agency reports, confirmed that the investigation was incomplete. The SSD and Administrator both acknowledged that investigating such allegations was a group effort, but the Administrator stated that she expected the investigation to include staff interviews, which did not occur. This failure to follow investigative protocols resulted in an incomplete investigation of the alleged misappropriation.
Failure to Update Care Plan After Fall and New Medical Orders
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented to address all of a resident's medical needs and preferences. Specifically, after a resident with a history of stroke and morbid obesity experienced a fall from a wheelchair during van transport, no fall incident report was completed, and no new interventions were added to the care plan. The Director of Nursing acknowledged that the event was initially considered a motor vehicle accident rather than a fall, resulting in the omission of required post-fall assessments and care plan updates. Additionally, the care plan did not reflect the resident's preference for sitting on multiple items in the wheelchair, such as a dycem, various cushions, sheepskin, and a bath blanket, nor did it mention the use of a lumbar back support, despite these being regularly used and observed by staff and confirmed by the resident. Further, a physician's order for the resident to bear weight on the right foot in a CAM boot was not incorporated into the care plan or the CNA Kardex. These omissions demonstrate that the facility did not update the care plan to include new medical orders or the resident's specific needs and preferences, as required by facility policy and standard care protocols. The lack of documentation and care plan updates following the fall and the introduction of new medical equipment contributed to the deficiency identified during the survey.
Failure to Prevent Accident Hazard During Wheelchair Transport
Penalty
Summary
A deficiency occurred when a resident, who had a history of stroke with right-sided weakness and morbid obesity, was transported in a wheelchair while sitting on multiple items, including a dycem, cushion, and bath blanket. The wheelchair was not equipped with only manufacturer-approved cushioning, and these additional items were not removed prior to transport. During the van ride, the driver applied the brakes suddenly to avoid a deer, causing the resident to slide under the safety belts and fall onto the wheelchair foot pedals. The resident's right foot became pinned between the wheelchair wheel and the seat belt device on the van floor, resulting in a right ankle fracture that required hospital treatment. Observation, interview, and record review confirmed that the environment was not free from accident hazards, as the use of multiple non-standard items in the wheelchair contributed to the resident's fall and injury. The CNA accompanying the resident and the van driver were unable to assist the resident after the fall, necessitating emergency services to extricate and transport the resident to the hospital. The Director of Nursing acknowledged that the presence of multiple items in the wheelchair could have contributed to the hazard.
Failure to Ensure Nurse Competency and Proper Venipuncture Practices
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the specific competencies and skill sets necessary to meet residents' needs, affecting all 42 residents. One incident involved a male resident admitted for rehabilitation after abdominal surgery, where an LPN performed a venous blood draw from the resident's foot without documented evidence of appropriate training or competency in this procedure. The facility did not have a policy or procedure in place regarding venipuncture from non-standard sites, and staff interviews revealed uncertainty about proper protocols and training requirements for blood draws from locations other than the arms or hands. Review of staff records showed that the LPN involved had not received documented training in venipuncture, and her most recent education did not cover this skill. Other nursing staff hired since February of the same year also lacked evidence of training or competency evaluations. Interviews with RNs and the DON confirmed that there was no standard policy or procedure for venipuncture, and that training and competency documentation was missing for several staff members. Staff expressed varying understandings of which anatomical sites were appropriate for blood draws and what training was required. The facility was unable to provide requested policies, procedures, or documentation of training and competency evaluations for licensed nurses, both upon hire and annually. The DON acknowledged the absence of such documentation and stated that, at the time, there was no evidence of licensed nurse training or competency evaluation since February. This lack of a system to evaluate and document nurse competencies contributed to the deficiency identified by surveyors.
Failure to Develop Care Plans for Anticoagulant Use and Bleeding Risk
Penalty
Summary
The facility failed to develop and implement person-centered care plans addressing anticoagulant use and risk for bleeding for two residents. One resident, a female with a history of atrial fibrillation and anemia, was prescribed anticoagulants (Xarelto and later Pradaxa) following hospitalization for post-surgical knee sepsis. Despite her diagnoses and medication changes, there was no care plan in place to address her anticoagulant therapy or associated bleeding risks, even after a hospital readmission for anemia and complications related to anticoagulant use. Similarly, another resident with a history of stroke, peripheral vascular disease, and blood clots was admitted with an order for Pradaxa, but also lacked a care plan for anticoagulant use or bleeding risk. Interviews with nursing staff and the Director of Nursing revealed that care plans are typically initiated by the MDS Coordinator and updated by various departments, with information communicated to CNAs through reports, Kardex, or other documentation. However, there was no evidence that care plans specific to anticoagulant use or bleeding risk were created or maintained for these residents. Staff were unable to explain the absence of these care plans, and there was inconsistency in how updates were communicated to CNAs, with no set routine for reviewing the Kardex. The facility's own policies require comprehensive care plans based on thorough assessments and incorporation of risk factors, including monitoring for complications related to anticoagulation, but these were not followed for the affected residents.
Failure to Prevent Resident Sexual Exposure
Penalty
Summary
The facility failed to protect residents from sexual abuse by not implementing effective interventions to prevent a resident from exposing his genital area to others. Despite being aware of the resident's ongoing behavior of inappropriate nudity and sexual comments, staff interventions were limited to placing a blanket on his lap, which was repeatedly reported as ineffective. Multiple staff members acknowledged that the blanket did not consistently cover the resident, and there were no new or alternative interventions put in place after the incident where the resident exposed himself in a common area in proximity to two other residents, both of whom had severe cognitive impairment. The resident with a history of inappropriate display of nudity and sexual comments had diagnoses including Alzheimer's dementia, enlarged prostate, stroke, overactive bladder, urinary retention, and cognitive communication deficit. The care plan had not been updated with effective strategies since the last modification several months prior to the incident. Staff interviews confirmed awareness of the behavior and the ineffectiveness of current interventions, yet no additional measures were implemented to prevent recurrence, resulting in continued exposure of other vulnerable residents to inappropriate conduct.
Failure to Label and Date Perishable Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food safety by not labeling and dating perishable items in the refrigerator. During an initial tour of the kitchen, a surveyor observed several food items that were not labeled correctly. These included an open bag of cherry jam with an open date of December 2nd, chopped onions in an unlabeled container, an open milk jug without an open date, a V8 juice with only a received date and visibly separated contents, and a tub of leftover pulled pork that was neither labeled nor dated. Interviews with the interim Kitchen Supervisor and the Registered Dietitian revealed that the facility's policy required all leftovers and opened items to be labeled with open dates and discarded if not used within seven days, in accordance with the federal food code. The interim Kitchen Supervisor acknowledged the oversight and confirmed that the staff should have labeled the items and discarded those past the seven-day limit. The Registered Dietitian also confirmed the policy and noted that education had been provided to staff to ensure compliance.
Improper Storage and Labeling of Insulin
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, specifically insulin, which had the potential to affect several residents. During an observation, a surveyor found 16 unopened insulin pens and one bottle of Humalog stored in a refrigerator that was out of the acceptable temperature range, with the thermometer reading 28°F, below the required 36°F-46°F range. The temperature logs for the refrigerator were incomplete, with missing entries for November and December 2024, and several days in January 2025 showing temperatures below freezing. The Director of Nursing (DON) acknowledged that the nursing staff is responsible for maintaining the refrigerators and temperature logs. Additionally, a resident with diabetes mellitus II had an insulin pen with a pharmacy label that did not match the physician's orders. The label indicated administration at bedtime, while there were two orders for daily administration. The Registered Nurse (RN) confirmed the discrepancy and stated that the medication should have been sent back to the pharmacy for correct labeling. The DON recognized the potential harm of incorrect labeling and stated the expectation for medications to be correctly labeled according to facility policy.
Resident Unable to Access Sink for Personal Hygiene
Penalty
Summary
The facility failed to reasonably accommodate the personal needs of a resident, identified as R21, who was unable to access or use the sink in his room. R21, who has Parkinson's disease and uses a wheelchair and a walker for mobility, was observed by a surveyor attempting to brush his teeth and wash his hands without success due to the sink's location in a corner, which was inaccessible with his wheelchair or walker. Despite his efforts to reach the sink, R21 was unable to do so and attempted to stand, risking his safety, without any staff assistance present. Interviews with the resident, his family member, and facility staff revealed that the issue was known but unaddressed. The Certified Nursing Assistant (CNA) acknowledged that R21 could not reach the sink, and the Director of Nursing (DON) was unaware of the problem. This lack of awareness and action from the facility staff contributed to the deficiency, as R21 was unable to perform basic hygiene tasks independently or with assistance, compromising his personal care needs.
Failure to Assist Resident with Hand Hygiene
Penalty
Summary
The facility failed to ensure that a resident, identified as R21, received necessary assistance with hand hygiene after toileting and during personal care activities. R21, who has diagnoses including Parkinson's disease and non-Alzheimer's dementia, requires substantial assistance with activities of daily living, including personal hygiene. Observations by the surveyor revealed that R21 was not offered hand hygiene services after using the bathroom or during other personal care activities. This was despite the facility's policy emphasizing hand hygiene as a primary means to prevent infection spread. Interviews with staff and family members highlighted the issue further. R21's family member reported difficulties accessing the sink due to space constraints, which R21 confirmed, stating that his wheelchair and walker could not fit in front of the sink. Staff members, including CNA J, acknowledged the oversight in not assisting R21 with hand hygiene, despite knowing the resident's limitations. The Director of Nursing expressed expectations for staff to assist residents with hand hygiene, indicating a gap between policy and practice in the facility.
Failure to Implement Wound Care Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident 137, who was admitted with a foot wound, did not receive the necessary treatment as per the orders received upon admission. The facility's policy on the prevention of skin breakdown was not followed, as the resident's wound on the right big toe was not treated despite being identified during an initial skin evaluation. The wound was categorized as a vascular wound, but there was no indication of a venous wound in the diagnosis or treatment orders. The Director of Nursing (DON) admitted that an order from the Nurse Practitioner to apply a mepilex to the wound was not entered into the system, resulting in a lack of treatment for the resident's wound. The surveyor observed the resident's untreated wound on multiple occasions, and the DON acknowledged that the order should have been implemented upon admission. Despite the oversight, there were no changes in the condition of the wound during the resident's stay at the facility.
Inadequate Supervision and Safety Device Use for Residents
Penalty
Summary
The facility failed to ensure the safety of residents R21 and R30 through adequate supervision and the use of safety devices. For R21, who has Parkinson's disease, encephalopathy, and non-Alzheimer's dementia, the staff did not use a gait belt during transfers, despite the facility's policy requiring it for residents needing assistance. Observations showed that R21 was left unsupervised while brushing his teeth and was transferred without a gait belt during showering and toileting, contrary to the care plan and staff expectations. For R30, who has dementia and a history of falls, the facility did not update the care plan with new interventions following a fall on 12/30/24. Despite having a moderate fall risk score, the care plan lacked documentation of the intervention to toilet the resident before supper, which was noted after the fall. The Director of Nursing acknowledged the oversight in updating the care plan, which is crucial for preventing further falls and potential injuries. These deficiencies highlight the facility's failure to adhere to its policies and care plans, resulting in inadequate supervision and safety measures for residents at risk of falls. The lack of proper documentation and implementation of interventions for R30's fall risk and the failure to use gait belts for R21's transfers demonstrate a significant lapse in ensuring resident safety.
Inadequate Justification for Monthly Catheter Changes
Penalty
Summary
The facility failed to ensure that a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The deficiency was identified when the facility was unable to provide a medical justification for changing a resident's indwelling Foley catheter on a monthly basis. The Centers for Disease Control and Prevention (CDC) guidelines suggest that catheters should be changed based on clinical indications such as infection, obstruction, or when the closed system is compromised, rather than at routine, fixed intervals. However, the facility's policy did not include standards for the frequency of catheter removal, and the Treatment Administration Record indicated that the resident's catheter was being changed monthly without documented clinical justification. The resident involved, identified as R24, was admitted to the facility with diagnoses including respiratory failure, severe protein-calorie malnutrition, cognitive communication deficit, abnormal weight loss, and dysphagia. The resident had an order for an indwelling Foley catheter to be changed every 23 days and as needed for urinary retention. During the survey, the Director of Nursing was unable to provide a physician's justification for the monthly catheter changes and indicated that they would need to reach out to urology for records. Despite efforts to obtain medical records from a urology visit, the facility was unable to provide a medical reason for the monthly catheter changes before the survey concluded.
Failure to Conduct Lung Assessments with Nebulizer Treatments
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with chronic obstructive pulmonary disorder (COPD), specifically in the administration of nebulizer treatments. The resident, who was admitted with a diagnosis of COPD, was observed receiving a nebulizer treatment without a lung assessment being conducted before and after the treatment. The Registered Nurse (RN) involved only measured the resident's pulse and oxygen saturation prior to the treatment and did not perform a lung assessment, which is a standard of nursing care for nebulizer treatments according to the National Library of Medicine. Interviews with the RN and the Director of Nursing (DON) revealed a lack of awareness and training regarding the necessity of lung assessments in conjunction with nebulizer treatments. The RN admitted to not performing lung assessments unless specifically ordered by a doctor, and the DON confirmed that the facility did not have a policy requiring such assessments unless ordered. The resident also confirmed that lung assessments were never conducted before or after treatments, nor were they instructed to rinse their mouth or expectorate post-treatment, which are part of the standard care practices for nebulizer treatments.
Deficiency in Trauma-Informed Care for Resident
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident identified as a trauma survivor. The resident, who was admitted with diagnoses including PTSD and major depression, was not comprehensively assessed for their history of trauma, potential triggers for re-traumatization, or specific approaches to mitigate these triggers. The resident's care plan lacked documentation of trauma-informed care strategies and did not include personal cultural preferences or resident-specific interventions to prevent re-traumatization. Interviews with facility staff revealed a lack of awareness and follow-through regarding the resident's trauma history and care needs. A Certified Nursing Assistant was unaware of the resident's past trauma, and the Director of Nursing indicated that the Social Services Director had not completed the necessary care planning for PTSD. The facility did not conduct ongoing assessments or monitor the effectiveness of interventions to ensure they met the resident's goals, leading to a deficiency in providing appropriate care for the resident's trauma-related needs.
Facility Lacks Policy for Lost Dentures, Fails to Provide Dental Care
Penalty
Summary
The facility failed to have a policy identifying the circumstances under which the loss or damage of dentures would be the facility's responsibility. This deficiency was observed in the case of a resident, referred to as R5, who lost their partial upper denture on November 1, 2024. Despite the resident's intact cognitive status and ability to communicate effectively, the facility did not provide a policy specific to missing dentures, nor did they promptly refer the resident for dental services within three days of the dentures being reported missing. R5, who was admitted with diagnoses including diabetes mellitus II, anemia, anxiety, and a cognitive communication deficit, reported the missing dentures to various staff members, including CNAs, nurses, the Social Services Director (SSD), and the Nursing Home Administrator (NHA). The resident expressed that the missing dentures affected their ability to eat and made them self-conscious, yet no dental services were provided after the dentures were reported missing. The facility's investigation into the missing dentures, led by the SSD, concluded without locating the dentures or offering to replace them, citing that the facility was not responsible unless negligence could be proven. The facility's NHA confirmed the absence of a specific policy for lost or missing dentures and stated that the facility was not responsible for replacing the dentures as they were not proven to be lost due to staff negligence. The resident handbook, which was provided to all residents upon admission, was referenced as outlining the facility's policy on missing items, indicating that the facility is not responsible for lost or missing personal items. Despite the resident's grievance being documented, no follow-up actions were taken to assist the resident in obtaining new dentures or scheduling a dental appointment.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during care for two residents. For one resident, a Certified Nursing Assistant (CNA) did not perform hand hygiene between different care tasks. The CNA assisted the resident with personal hygiene, changed the lift sheet, and handled personal items without removing gloves or performing hand hygiene until the end of the care session. This action was contrary to the facility's hand hygiene policy, which emphasizes hand hygiene as a primary means to prevent infection spread. Additionally, a Registered Nurse (RN) failed to disinfect reusable medical equipment after use. The RN used a blood pressure cuff and pulse oximeter to assess a resident's vitals and returned the equipment to the medication cart without disinfecting it. This was against the facility's policy, which requires disinfection of reusable items between residents to prevent infection transmission. Another deficiency involved a resident who required enhanced barrier precautions due to an indwelling medical device. The facility did not have the necessary signage or personal protective equipment (PPE) cart outside the resident's room, as required by the facility's policy. This oversight was discovered during a surveyor's observation, and the Director of Nursing was surprised to find the absence of the required precautions, which are essential for infection control in residents with specific medical conditions.
Facility's Admission Packet Requires Waiver of Liability for Personal Property
Penalty
Summary
The facility failed to ensure that its admission packet did not require residents to waive potential facility liability for losses of personal property. This deficiency was identified during a policy review and interview with the Nursing Home Administrator (NHA). The facility's Resident Handbook, dated 2023, states that while the facility aims to keep residents' items safe, it is not responsible for replacing misplaced items. During an interview, NHA A confirmed that the handbook is provided to all residents and reiterated that the facility does not reimburse or replace missing items unless the loss is directly linked to staff negligence. This policy potentially affects all 33 residents residing in the facility.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to residents and their representatives, as well as the ombudsman, for four residents who were hospitalized. This deficiency was identified through interviews and record reviews conducted by surveyors. The facility did not ensure that the residents and their representatives were informed in writing about the transfer or discharge and the reasons for the move in a language and manner they could understand. Resident R24 was admitted with diagnoses including non-ST elevation myocardial infarction and unspecified psychosis. R24 was sent to the emergency room for a suspected rib fracture and returned to the facility without receiving a written notice of transfer. Similarly, Resident R22, who had diagnoses such as respiratory failure and severe protein-calorie malnutrition, was transferred to a hospital due to respiratory distress but did not receive a written notice of transfer. Resident R20, with conditions including osteomyelitis and atrial fibrillation, was transferred to the hospital for an infection requiring antibiotic therapy, yet no documentation of a written notice of transfer was found. Resident R21, diagnosed with Parkinson's disease and non-Alzheimer's dementia, was hospitalized due to altered mental status. Despite the presence of R21's wife during the transfer and the facility's communication with the physician, no written notice of discharge or transfer was documented. Interviews with facility staff, including the Social Services Director and Director of Nursing, revealed confusion and inconsistency in the process of providing written notifications of transfer, contributing to the deficiency.
Deficiency in Daily Nurse Staffing Information Posting
Penalty
Summary
The facility failed to post the required daily nurse staffing information correctly, as observed by surveyors. Over a 30-day period, the facility did not consistently include the resident census and the facility name on the daily postings. Specifically, on two separate occasions, surveyors observed that the daily postings near the elevator were missing both the daily resident census and the facility name. A review of the last 30 daily postings revealed that 17 postings were missing the daily resident census, and six postings were missing the facility name. Additionally, six postings were missing both the facility name and the resident census. During an interview, the Director of Nursing (DON) acknowledged the expectation that all required information should be present on each daily posting and recognized the need for a better system to ensure compliance.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required timeframe. A family member of a resident reported that a Certified Nursing Assistant (CNA) allegedly bent the resident's fingers back to cause pain in an attempt to make the resident stand up. This incident resulted in bruising to the resident's knuckles and hand. Despite the facility's policy requiring immediate reporting of such allegations to various authorities, including the State Agency, the incident was not reported as required. The resident involved had a range of medical conditions, including moderate cognitive impairment, and required assistance with activities of daily living. During the investigation, the Nursing Home Administrator stated that the facility followed a flowchart for determining reporting requirements, which incorrectly indicated that the incident was not reportable. However, upon review, it was noted that the flowchart was not applicable to nursing homes. Both the Director of Nursing and the Facility Owner acknowledged that the incident should have been reported to the State Agency, as it involved allegations of abuse and injury.
Failure to Provide Timely Neurological Assessment Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. The resident, who had a history of Alzheimer's disease, atrial fibrillation, nonrheumatic mitral valve insufficiency, and atherosclerotic heart disease, experienced a change in condition that was not properly assessed by the staff. Despite showing signs of a stroke, comprehensive neurological assessments were not completed, and a Registered Nurse did not assess the resident as the condition continued to deteriorate. Throughout the day, various staff members, including LPNs and RNs, noted the resident's unusual sleepiness and lack of responsiveness. However, the necessary neurological assessments were not conducted, and the resident's condition was not promptly reported to a physician. The resident's family was not informed in a timely manner, and the resident was not transferred to the emergency room until several hours later, by which time the resident had suffered a stroke and was subsequently placed on hospice care. Interviews with staff revealed a lack of communication and documentation regarding the resident's condition. The staff failed to follow the facility's neurological assessment policy, and documentation was completed the following day, rather than at the time of the events. The failure to assess and provide appropriate interventions for the resident led to serious harm, resulting in a finding of immediate jeopardy.
Removal Plan
- All nursing staff to be educated on change of condition policy and when to notify MD.
- Facility will do a house sweep to identify any other residents with a change of condition, with appropriate MD notification.
- Nursing staff will be educated on symptoms of a stroke by using the FAST (face, arms, speech, time) assessment.
- Nursing staff will be educated on proper neurological assessment.
Failure to Ensure Adequate Hydration and Nutrition
Penalty
Summary
The facility failed to ensure adequate fluid and food intake for three residents, leading to severe dehydration and malnutrition. One resident, admitted with multiple health issues including chronic kidney disease and morbid obesity, was not properly assessed for hydration needs. Despite having a documented fluid requirement of 2,400 ml, the resident's daily fluid intake was significantly below this level, often less than 500 ml. The facility did not develop a care plan to address the resident's hydration needs, failed to monitor fluid intake accurately, and did not communicate the resident's inadequate fluid intake to the physician. This neglect resulted in the resident being hospitalized with severe dehydration and eventually passing away. Another resident, who was readmitted after a stroke, did not have an updated nutritional assessment or care plan to address their hydration and nutritional needs. The resident was observed to be totally dependent on staff for care, yet there was no documentation of intake or output monitoring. The family expressed concerns about the resident's NPO status and requested that the resident be offered pleasurable foods, but the facility did not address these requests or assess the resident's ability to safely consume food and fluids. A third resident, with a history of stroke and malnutrition, was identified as being at high risk for dehydration. However, the resident's care plan did not include any interventions or revisions to address this risk. The facility failed to monitor the resident's fluid intake adequately, and there was no evidence of a comprehensive care plan to prevent dehydration. Despite being on a list for monitoring, the resident's hydration status was not fully addressed, leaving them vulnerable to potential harm.
Removal Plan
- All nursing staff educated on facility policy for tracking fluids/hydration at the facility, including reviewing hydration, notifying MD, and new hydration assessments.
- Facility completed a house sweep for all residents at risk for dehydration, using a dehydration assessment to determine who is at risk.
- All at risk residents with less than 1500ml daily intake will be reviewed weekly at Resident at Risk Meetings.
- All residents at risk for dehydration will have updated care plans.
- Facility reviewed the dehydration procedures in coordination with Nursing, IDT, and Dietitian, including how the facility tracks hydration, reviews dehydration, and follows up on residents at risk.
- Facility updated the hydration assessment and follows residents who scored an 8 or higher.
- All residents at risk who consume less than 1500ml will be reviewed and physician will be notified.
- Hydration policy updated related to required components on dehydration being available for nurses to use/follow.
- Facility will review dehydration assessments/update care plans on admission, quarterly, and as needed.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in treatment and documentation. One resident, who was readmitted with multiple diagnoses including Alzheimer's disease and a recent stroke, developed a deep tissue injury on the left heel due to inadequate repositioning and lack of protective measures. Despite being identified as high risk for pressure injuries, the resident's care plan did not include interventions for pressure injury prevention, and staff failed to reposition the resident every two hours as required. Observations revealed that the resident's heels were not off-loaded, and staff did not implement necessary protective measures even after the injury was noted. Another resident developed a stage 4 pressure injury on the lumbar spine, which required surgical intervention and subsequent hospitalization. Upon return to the facility, the resident's wound care was inadequately documented, with no weekly assessments or detailed descriptions of the wound's condition. The wound continued to drain, indicating it was not healed, yet the facility's wound nurse was unaware of the need for continued documentation and mistakenly believed the wound was a surgical wound rather than a pressure injury. This lack of documentation and awareness led to a delay in identifying an infection, which was only addressed after a culture was taken by an external wound clinic. The deficiencies in care and documentation for both residents highlight a failure to adhere to established guidelines for pressure injury prevention and treatment. The facility did not ensure that residents at risk for pressure injuries received appropriate interventions, nor did it maintain accurate and timely records of wound assessments. These oversights resulted in actual harm to the residents, as evidenced by the development and progression of pressure injuries.
Deficiency in CNA In-Service Training
Penalty
Summary
The facility failed to ensure that two out of five Certified Nursing Assistants (CNAs), who have been employed for more than one year, received the required minimum of 12 hours of in-service training annually. This deficiency was identified during a survey conducted on 09/23/24, where the surveyor requested documentation of in-service training hours for CNAs BB and DD. CNA BB, hired on 09/16/22, and CNA DD, hired on 12/22/15, did not receive the necessary training in areas such as communication, behavioral health, and dementia care. Despite multiple requests from the surveyor, the facility was unable to provide the required documentation. The Nursing Home Administrator (NHA) admitted that there was no current process in place to ensure CNAs completed the annual training requirement, which was under review for correction.
Improper Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the area of hand hygiene during meal distribution. Dietary Aide (DA) S was observed handling meal tickets, which are not cleanable surfaces, and then directly touching ready-to-eat foods without changing gloves or performing hand hygiene. This improper practice was noted during the serving of meals to five residents, where DA S touched various food items such as buns and pizza after handling meal tickets. The facility's policy, dated April 2019, clearly states that bare hand contact with food is prohibited and that gloves should be changed between tasks. However, DA S did not follow these guidelines, leading to potential contamination of the food served to the residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper hygiene and personal protective equipment (PPE) protocols. In one instance, a Certified Nursing Assistant (CNA) used a mechanical lift to transfer a resident without sanitizing it after prior use in another resident's room. Additionally, staff did not perform hand hygiene with glove changes during incontinent care for residents, and failed to wear gloves when obtaining a blood sample for blood glucose monitoring. Further deficiencies were noted when staff entered a resident's room labeled for Droplet Precautions without wearing the required PPE, such as masks and eye protection. This was compounded by a lack of awareness among staff about the transmission-based precautions in place, as evidenced by a CNA's admission of not knowing the necessary PPE requirements and a Licensed Practical Nurse (LPN) initially being unsure of the resident's precautionary status. Additional observations included staff not wearing gowns during high-contact care activities for residents on enhanced barrier precautions, and failing to sanitize hands or change gloves appropriately during care procedures. These lapses in protocol were observed across multiple staff members and residents, indicating a systemic issue with adherence to infection control policies within the facility.
Failure to Notify Physician of Low Blood Pressure
Penalty
Summary
The facility failed to promptly notify and consult with a resident's physician when there was a deterioration in the resident's clinical condition. The resident, identified as R12, exhibited symptoms of low blood pressure on multiple occasions, with readings below 100/60 mm/hg. Despite the facility's policy requiring that hypotension be reported to the physician, the physician was only notified on two out of fourteen instances of low blood pressure. This lack of notification was contrary to the orders that required the monitoring of blood pressure every shift and updating the physician with any concerns. R12 was admitted with several diagnoses, including cellulitis, morbid obesity, muscle weakness, hypertension, atrial fibrillation, heart failure, diabetes with neuropathy, and atherosclerotic heart disease. The facility's failure to notify the physician of the low blood pressure readings was confirmed through record reviews and interviews with the Director of Nursing and the resident's physician. The physician indicated that staff should follow the set parameters for blood pressure and notify them immediately of any irregularities, which was not adhered to in this case.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure privacy for a resident during personal care, as observed by a surveyor. The resident, who was readmitted with Alzheimer's disease and other medical conditions, was noted to have impaired cognition and was dependent on staff for personal care. The surveyor observed multiple instances where the resident's privacy was compromised, including the resident's breast being exposed to the hallway due to the room door being open and the privacy curtain not being used. Additionally, the resident's care plan had not been updated since 2021, despite a significant change in the resident's status. During personal care, staff members were observed leaving window blinds open and not using the privacy curtain, resulting in the resident's breasts and genital area being exposed. The surveyor noted that staff did not attempt to cover the resident or ensure privacy during these care activities. Family members and a Licensed Practical Nurse expressed concern about the lack of privacy, and the Director of Nursing acknowledged that the expectation was to provide privacy by closing blinds and using privacy curtains during care.
Neglect in Resident Care and Hygiene
Penalty
Summary
The facility failed to provide necessary care and assistance for a resident, identified as R1, who was unable to perform activities of daily living. R1 was readmitted with multiple diagnoses, including Alzheimer's disease and atherosclerotic heart disease, and was assessed as having impaired cognition. Despite being dependent on staff for most personal care activities, the facility did not update R1's care plan since 2021, and the Minimum Data Set (MDS) was not completed to reflect R1's current physical functionality. Surveyors observed R1 in a state of neglect over several days. R1 was found lying in bed with disheveled hair, a dried substance on the face, and a strong smell of urine in the room. The catheter bag was observed lying on the floor, and R1's sheets were bunched up and soaked with a dark brown liquid. Despite these conditions, staff did not provide adequate care, such as repositioning, grooming, or oral hygiene. Family members expressed concern about R1's condition, noting that R1 was often left in a hospital gown with bunched-up sheets and a persistent urine odor. Interviews with staff, including CNAs and the Director of Nursing, revealed a lack of adherence to care protocols. CNAs admitted to not performing necessary hygiene tasks, such as offering mouth swabs for oral care. The Director of Nursing acknowledged that staff were expected to provide comprehensive personal care to R1, who was entirely dependent on them. However, observations and interviews indicated that these expectations were not met, leading to the deficiency in care for R1.
Inadequate Catheter Care and Assessment
Penalty
Summary
The facility failed to ensure proper care and assessment for a resident with an indwelling Foley catheter, as there was no physician order directing the care and treatment for the catheter. The resident, who was readmitted with multiple diagnoses including Alzheimer's disease and atherosclerotic heart disease, was observed to have impaired cognition and was dependent on staff for all care. Despite these needs, the facility did not update the resident's care plan since 2021, and the Minimum Data Set (MDS) assessment was not completed to reflect the resident's current physical functionality. Surveyors observed several instances where the resident's catheter care was inadequate. The catheter bag was found lying on the floor with very little output, and the urine was reddish dark brown with sediment. Staff failed to report or address these issues adequately, as evidenced by the lack of communication between CNAs and LPNs regarding the catheter's condition. The resident was observed to be in pain, moaning, and holding their abdomen, yet staff did not assess for abdominal distention or other complications associated with the catheter. The Director of Nursing acknowledged that staff should have been checking for abdominal distention and ensuring the catheter was draining properly. However, observations showed that staff did not follow the facility's catheter policy, leading to the resident's discomfort and potential complications. The lack of proper assessment and communication among staff contributed to the deficiency in care for the resident with the indwelling Foley catheter.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to ensure proper procedures were followed for the administration of insulin using insulin pens, as observed by a surveyor. Specifically, a Licensed Practical Nurse (LPN) did not perform the necessary safety check of priming the needle on insulin pens before administering insulin to two residents, R8 and R11. The manufacturer's instructions for insulin pens clearly state that priming is essential to remove air from the needle and cartridge, ensuring the correct dose is administered. However, during the administration of insulin to R8 and R11, the LPN did not prime the needle with 2 units before dialing the pen to the prescribed dose, which is a critical step to verify the pen's functionality and ensure the residents received the correct insulin dosage. Upon inquiry, the LPN incorrectly stated that priming the needles on insulin pens was not required, indicating a lack of adherence to the facility's policy and procedure. The Director of Nursing (DON) confirmed that the facility's policy mandates priming the needle with 2 units before administering the prescribed dose. The surveyor's observations and subsequent interviews revealed that the LPN's actions were not in compliance with the established procedures, leading to the deficiency in the administration of pharmaceutical services to meet the needs of the residents.
Improper Storage and Labeling of Insulin Pens
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to accepted professional principles, as observed in the case of a resident's room. Insulin pens were found unattended on a bedside table in the resident's room while the resident was away for dialysis. The insulin pens, including a Humalog pen with 140 units left and an Insulin Glulisine pen with 60 units left, were not stored in a locked compartment as required. Additionally, the Humalog pen was expired and lacked an open date, and neither pen was capped. The resident expressed a desire to self-administer medications and had a lock box in the room for insulin storage. However, the lock box was not easily accessible from the bed, leading the resident to keep the insulin pens on the bedside table for convenience. The resident was unaware of the expired status of the Humalog pen, as they had not needed it recently due to dietary management. The Director of Nursing was unaware of the resident's practice of storing insulin in their room and acknowledged that expired medications should not be available to residents.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure injuries for a resident identified as high risk. The resident, who had diagnoses including osteomyelitis, type 2 diabetes, venous insufficiency, and a heel fracture, developed an unstageable pressure injury on the right foot and a stage II pressure injury on the right buttock. The facility did not conduct weekly comprehensive assessments of these injuries, nor did they implement preventative pressure-relieving measures as required by their policy and national guidelines. The resident's care plan lacked specific interventions to address the pressure injuries and the risk of skin breakdown. Although the care plan included general interventions related to diabetes management, it did not address the specific needs for preventing friction and shearing that contributed to the pressure injuries. Observations during the survey revealed that the resident's feet were not properly elevated, and the prescribed heel riser and pool noodle were not in use, leading to the resident's foot resting against the bed's footboard, potentially exacerbating the injury. Interviews with facility staff, including the Director of Nursing and nursing staff, revealed a lack of clarity and responsibility for completing weekly wound assessments after the departure of an employee who previously handled these tasks. The facility's failure to conduct timely and comprehensive skin assessments and implement effective interventions resulted in actual harm to the resident, as evidenced by the worsening of the pressure injuries.
Delayed Reporting of Potential Misconduct Involving Feeding Tube
Penalty
Summary
The facility failed to report an incident of potential misconduct involving a resident's feeding tube in a timely manner. The incident occurred when a Certified Nursing Assistant (CNA) flushed a resident's PEG/G-tube with warm water, which was outside the scope of her practice. This action was identified as potential abuse, neglect, or mistreatment by the facility. The incident was discovered on June 28, 2024, but was not reported to the state agency until July 10, 2024, which was beyond the required reporting timeline. The facility's policy mandates that all alleged violations involving neglect must be reported immediately, but not later than 2 hours after the allegation is made, or not later than 24 hours, to the administrator, who must then report to the state survey agency within 5 working days. The Director of Nursing (DON), who was responsible for preparing the misconduct incident report, was new to her position and unfamiliar with the state-required timeline and submission process. The DON was guided by the facility's corporate nurse in the investigation process and submission to the state. Despite the completion of most of the investigation by the DON, the initial report was not submitted promptly, resulting in a delay. The incident report noted that the CNA's actions were outside her scope of practice, and the resident questioned when the CNA became a nurse, indicating a lack of proper role understanding and execution.
Inadequate Investigation of CNA's Scope of Practice Violation
Penalty
Summary
The facility failed to conduct a thorough investigation and take appropriate corrective actions regarding an alleged violation involving a resident's feeding tube. A Certified Nursing Assistant (CNA) flushed a resident's feeding tube with warm water, which was outside her scope of practice. The incident was reported by a Therapeutic Medication Aide (TMA) who witnessed the CNA's actions and expressed concern. The facility's investigation was limited, with insufficient staff interviews and no resident interviews conducted to determine if similar incidents had occurred. The Director of Nursing (DON) acknowledged that the investigation was incomplete, as not all nursing staff were interviewed, and there was no evidence of post-incident education provided to staff regarding the scope of practice for CNAs. The report noted that the CNA claimed she was instructed by a Registered Nurse to perform the task, but the RN and other nurses denied giving such instructions. The facility's policy requires thorough investigations of alleged violations, but the evidence showed that this was not achieved in this case.
Improper Feeding Tube Management by CNA
Penalty
Summary
The facility failed to ensure that services were provided by a qualified person in accordance with a resident's written plan of care. A Certified Nursing Assistant (CNA) improperly flushed a resident's feeding tube with warm water, which was outside her scope of practice. The resident, who required tube feeding due to a swallowing problem, had specific orders for the feeding tube to be flushed four times daily. However, the CNA, who was not qualified to perform this task, took it upon herself to flush the tube after finding it unattached, claiming she had seen others do it and was instructed by a Registered Nurse (RN) to do so. The RN denied giving such instructions, and the CNA could not recall who else might have asked her to perform tasks outside her scope. The incident was reported, and an investigation was conducted by the Director of Nursing (DON). Despite the investigation confirming the CNA's actions were outside her scope of practice, there was no evidence that the facility provided post-incident education to the nursing staff regarding the scope of practice for CNAs. The lack of documented education following the incident highlights a gap in ensuring that all staff are aware of their professional boundaries and responsibilities.
Failure to Provide Necessary Treatment for Non-Pressure Injuries
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services consistent with professional standards of practice, specifically for two residents with non-pressure injuries. Resident R4, who had diagnoses including diabetes mellitus, end-stage renal disease, and weakness, developed a facility-acquired non-pressure injury on his left heel. Despite documentation indicating that staff were checking R4's heels and feet twice daily, a weekly wound assessment inaccurately reported no skin concerns. By 07/16/24, R4 had developed two additional non-pressure injuries on his feet, and the initial injury had worsened, yet these were not documented in the weekly wound assessment. The facility's records showed multiple instances where required documentation and treatment were not completed as ordered. Physician orders for weekly skin assessments and daily checks of R4's feet and heels were not consistently documented. Additionally, treatment orders for R4's left heel were not followed on several occasions. Interviews with R4 and the Director of Nursing confirmed that staff were not checking R4's feet and heels as ordered, which contributed to the lack of timely intervention and documentation of R4's skin conditions.
Failure to Provide Supervision During Meals
Penalty
Summary
The facility failed to provide necessary supervision to prevent accidents for two residents, R6 and R11, during meal times. Both residents had specific care plans and caregiver instructions indicating the need for supervision while eating due to swallowing difficulties and other related issues. Despite these instructions, on the morning of July 23, 2024, both residents were observed eating breakfast without any staff supervision in the small lounge/dining area. R6 was noted to be eating without alternating food and drink, contrary to the swallowing strategies outlined in her care plan. Similarly, R11 was eating without supervision, despite her care plan indicating the need for a supervised setting during meals. The lack of supervision was confirmed through interviews with CNA D, who acknowledged that residents in the small dining room require supervision while eating. CNA D admitted that the current procedure involved serving residents in the dining room first and then leaving to serve room trays, which resulted in a lack of supervision for those in the dining room. The Director of Nursing, DON B, also confirmed that staff are expected to remain present to supervise residents who require it. This oversight in supervision led to the deficiency noted by the surveyors.
Inadequate Pain Management for Hospice Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident (R1) who was under hospice care with a terminal diagnosis. R1 had multiple serious health conditions, including vertebral osteomyelitis, lumbar fractures, and blood clots, and was admitted to the facility after hospitalization. Despite having a care plan that included administering medications as ordered and monitoring their effectiveness, the facility did not consistently follow these directives. R1 expressed increased pain using a pain scale, but the facility did not administer as-needed medications when R1's pain was elevated, nor did they document the effectiveness of these medications when used. The Medication Administration Record (MAR) indicated several instances where as-needed pain medications were administered without documenting their effectiveness. There were also periods where R1 experienced high pain levels for extended hours without receiving as-needed medications. For example, on one occasion, R1 had a high pain rating for approximately 3.25 hours without administration of as-needed pain medications. Additionally, there were instances where the effectiveness of administered medications was unknown or not documented, leaving gaps in the management of R1's pain. Interviews with facility staff, including an LPN, revealed that there were delays in receiving medications from the pharmacy, which contributed to the inadequate pain management. The LPN reported that R1 was physically uncomfortable and expressed symptoms of anxiety, and despite administering medications when they arrived, the LPN felt that R1's pain was not managed adequately. This lack of timely and effective pain management, along with insufficient documentation, highlights the facility's failure to adhere to R1's care plan and provide the necessary care to maintain R1's highest practicable physical well-being.
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Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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