Ingleside Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Horeb, Wisconsin.
- Location
- 407 N Eighth St, Mount Horeb, Wisconsin 53572
- CMS Provider Number
- 525331
- Inspections on file
- 27
- Latest survey
- October 13, 2025
- Citations (last 12 mo.)
- 61 (3 serious)
Citation history
Health deficiencies cited at Ingleside Manor during CMS and state inspections, most recent first.
A resident with multiple comorbidities was admitted with an abdominal wound that was not comprehensively assessed according to professional standards. Initial and ongoing wound assessments were incomplete, lacking documentation of key characteristics such as drainage, odor, and changes in size. Despite the wound increasing in size and developing a foul odor, there was no timely physician notification. The resident's condition worsened, leading to hospital readmission with a wound infection and septic shock.
Multiple residents reported and were observed to have unclean rooms, including visible debris, dried spills, and fecal matter, with staff confirming that housekeeping was not performed regularly due to staffing shortages. Facility policy requiring regular cleaning was not consistently followed, and there was insufficient communication with residents about their housekeeping concerns.
Multiple residents did not receive medications as ordered due to issues such as internet outages, medication unavailability, and untimely administration by nursing staff. Facility policies requiring timely medication administration and error reporting were not consistently followed, resulting in missed and delayed doses for residents with complex medical needs.
A resident with multiple chronic conditions was not consistently allowed to eat in the dining room as per her documented preference, due to staff failing to coordinate her morning care and shower schedule. Despite her care plan and meal tickets indicating her choice, she was served breakfast in her room instead of the dining room, which was confirmed by interviews with the CNA, DM, and DON.
A resident with a stage 2 pressure injury and multiple comorbidities did not receive prescribed pressure ulcer prevention interventions, including use of a pulsating mattress, pressure-relieving cushion, and regular repositioning. Staff failed to ensure these interventions were in place, and the care guidance provided to CNAs did not include necessary pressure injury prevention measures.
A resident with a suprapubic catheter was observed with their catheter tubing and drainage bag resting on the floor, contrary to facility policy and care plan instructions. Both a CNA and the DON confirmed that catheter equipment should not be on the floor, and the resident expressed concern due to a history of UTIs.
The facility did not develop or implement care plans for two residents with significant behavioral health needs—one with a substance use disorder and another with a history of suicidal ideation and attempts. Staff failed to assess, monitor, or provide interventions for these conditions, and the facility lacked a substance abuse policy. Key staff were unaware of the residents' behavioral health issues, and no referrals or precautions were put in place.
Two residents did not receive critical prescribed medications, including seizure medications and insulin, due to issues such as internet outages and unavailable drugs. Facility staff did not follow established policies for medication administration, failed to use available contingency supplies, and did not effectively communicate alternative procedures, resulting in significant medication errors.
Multiple residents reported and were observed to be affected by flies and ants in their rooms and common areas, with flies landing on a resident during an interview and others using fly swatters or sticky strips to manage the issue. Despite the facility's pest control policy, staff and maintenance acknowledged ongoing pest problems and could not confirm an effective plan to address the infestation.
A resident with type 2 diabetes had blood glucose readings above the ordered threshold on two occasions, but the physician was not immediately notified as required by orders and facility policy. Nursing staff and the DON confirmed that notification and documentation should have occurred at the time of the events, but records showed no timely communication with the provider.
An LPN suspected that a nurse may have taken medication from the med cart after accessing it without proper oversight, but did not immediately report this suspicion to the DON or NHA as required by facility policy. The LPN acknowledged knowing the reporting requirement but failed to act, and the NHA confirmed that no report was made.
A resident with impaired mobility due to osteoarthritis did not receive or have documentation for the required number of showers, as only a fraction of scheduled showers were recorded. Facility staff confirmed that showers were to be documented and that missing documentation meant the care was not provided, resulting in a failure to meet the resident's needs for personal hygiene and skin assessment.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to follow the established care plan.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident did not receive sufficient food and fluids to maintain their health, as required. The facility failed to ensure the necessary provision of nutrition and hydration.
A resident with multiple medical conditions and moderate cognitive impairment was not seen by a physician within the required timeframe after admission, as only a nurse practitioner visit was documented. The DON confirmed that the resident did not receive the mandated physician visits according to facility policy and federal regulations.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
Staff failed to follow infection control protocols during wound care and perineal care for two residents. An LPN did not perform hand hygiene between glove changes while treating a resident with lower limb wounds, and a CNA placed used washcloths and a towel inappropriately after pericare, contaminating clean areas. Both incidents were acknowledged by staff as breaches of the facility's infection prevention policies.
The facility failed to provide adequate supervision and implement required safety interventions for several residents, including one who eloped without staff knowledge, two who smoked without proper assessments or care plans, one who voiced suicidal ideations without appropriate follow-up, and another at risk for falls without documented interventions. These deficiencies were identified through observations, interviews, and record reviews, revealing lapses in assessment, care planning, and staff communication.
A resident did not receive enough food and fluids to maintain their health, as surveyors found that the facility did not adequately meet the individual's nutritional and hydration needs.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices. The report does not specify the actions or omissions that led to this deficiency or provide details about the individuals involved.
The facility did not complete annual performance evaluations for all CNAs and failed to provide the required 12 hours of annual in-service education for several staff, as confirmed by record review and administrator interviews. Documentation showed incomplete evaluations and insufficient education hours for multiple CNAs, with no specific policy in place for in-service education.
The facility did not ensure its QAA Committee included all required members, such as the Medical Director, and failed to meet at least quarterly as mandated. Sign-in sheets and administrator interviews confirmed these lapses, potentially affecting all residents.
The facility did not report several incidents, including a resident elopement and two resident-to-resident altercations, to the State Agency as required. Staff interviews revealed inconsistent training and understanding of reporting procedures for abuse, neglect, and altercations.
Staff interviews revealed inconsistent training on handling resident-to-resident altercations. While a CNA reported receiving training on deescalation and reporting, an LPN stated she had not received such training. An RN indicated prior training and referenced posted materials and communication tools for tracking incidents. The administrator confirmed the need for thorough investigation of all alleged violations.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided as required.
The facility did not maintain complete and accurate medical records for several residents, including missing documentation of a resident's change in condition and death, lack of nursing follow-up after a resident expressed suicidal ideation, and failure to document a resident-to-resident altercation in both involved residents' records. These actions did not meet facility policy or professional standards for medical recordkeeping.
A resident with impaired mobility and no cognitive impairment fell and struck her head when a Hoyer lift sling ripped during a transfer performed by a CNA and the DON. The sling used had been brought with the resident from the hospital. The incident was not documented in the EMR, and staff were unsure if an incident report was completed, despite facility policy requiring safe transfer techniques and proper documentation.
A resident experienced a significant change in eating habits, which was not promptly communicated to hospice or her family. Despite facility policies requiring notification of such changes, staff failed to inform the appropriate parties in a timely manner. The resident, who had diagnoses including senile degeneration of the brain and was utilizing hospice services, was eventually sent to the emergency room after hospice was notified several days later.
A facility failed to report a resident-to-resident abuse allegation within the required two-hour timeframe. The incident involved two residents, one with metabolic encephalopathy and the other with dementia and anxiety. The abuse was reported by a family member via email, leading to a delay in notifying the administration and the State Agency. Staff members were informed of the incident on the night it occurred and reported it to the nurse, but the administration was not aware until the next day.
A facility failed to thoroughly investigate a resident-to-resident abuse allegation involving two residents with cognitive impairments. The investigation did not include interviews with staff on duty during the incident, and inconsistencies were found in the information gathered. The Assistant Administrator acknowledged the investigation's shortcomings, leading to a deficiency.
A resident experienced late or missed medication administrations, contrary to the facility's policy requiring medications to be given within one hour of the prescribed time. The resident, with conditions including pulmonary hypertension and hypertension, reported receiving medications late and occasionally not at all, leading to chest pain and the need for nitroglycerin. The DON confirmed the late administrations.
The facility failed to maintain a medication error rate below 5%, with surveyors observing a 64.28% error rate. Three residents received their medications more than an hour late, contrary to facility policy. Delays were due to staff being new, behind schedule, or pulled to other tasks. Staff interviews revealed issues with pharmacy delays and lack of access to contingency supplies, impacting timely medication administration.
A resident with a history of heart failure experienced a significant change in condition, including weight gain and increased fatigue, which was not properly assessed or reported by the facility staff. Despite symptoms such as elevated heart rate and increased oxygen needs, the physician was not notified in a timely manner, resulting in the resident's hospitalization for atrial flutter and acute decompensated heart failure.
The facility failed to properly clean and disinfect the ice machine, potentially affecting all 56 residents. A surveyor observed a black film on the ice machine lid, and staff were unclear about cleaning responsibilities. The Maintenance Director admitted to cleaning the machine randomly, without a set schedule, despite the facility's policy requiring regular cleaning.
The facility failed to properly dispose of garbage, leading to unsanitary conditions around the main dumpster. Observations revealed waste such as used gloves, food waste, and stagnant water scattered on the ground. Interviews with staff, including the Dietary Manager and Maintenance Director, highlighted unclear responsibilities and inconsistent enforcement of cleanliness around the dumpster area.
The facility failed to establish a comprehensive infection prevention and control program, affecting all residents. The ADON/IP confirmed that only COVID-19 cases are tracked among staff, lacking a comprehensive line list for other infections. Additionally, infection control policies have not been updated annually, with some policies not revised since 2022 and 2023.
The facility failed to ensure that residents had access to call lights or a means to call staff for assistance. Four residents, including those with cognitive impairments and mobility issues, were observed or reported having call lights out of reach, leading to difficulties in obtaining staff assistance. The Nursing Home Administrator acknowledged the expectation for call lights to be accessible, highlighting a deficiency in meeting residents' needs.
The facility failed to maintain appropriate water temperatures, affecting several residents who reported cold water during showers and in bathroom sinks. Despite staff efforts to address the issue, the problem persisted, with some staff unaware or not reporting it to maintenance. This deficiency impacted residents' comfort and highlighted communication gaps within the facility.
The facility failed to notify physicians promptly about critical changes for two residents. One resident had a positive urine culture, but the provider was not informed, delaying treatment. Another resident missed nighttime medications, and the primary physician was not notified. The facility's policy requires immediate physician notification for abnormal lab results and missed medications, but this was not followed.
A facility failed to develop a comprehensive care plan for a resident on Eliquis, an anticoagulant, omitting necessary monitoring for side effects like bruising or bleeding. Despite the resident's severe cognitive impairment and history of falls, the care plan did not reflect the anticoagulant therapy or required monitoring. Staff interviews confirmed awareness of monitoring needs, but these were not documented in the care plan or medication records.
A resident at risk for pressure injuries developed a wound due to the facility's failure to implement a repositioning plan. Despite being dependent on staff for repositioning, the resident was not regularly repositioned unless assistance was requested. The wound was attributed to urinary catheter tubing under the resident's leg while in a recliner, highlighting inadequate preventive measures.
A resident at risk for malnutrition experienced significant weight loss due to inadequate monitoring of meal intake and inconsistent documentation. Despite being on a low fiber diet with specific dietary instructions, the resident's meal intake was poorly documented, with only 20 meals charted out of 246 over 82 days. Communication gaps and unclear responsibilities among staff contributed to the oversight of the resident's nutritional needs.
A resident with multiple health conditions did not receive their scheduled nighttime medications due to incomplete documentation of vital signs by the PM shift. The RN discovered the issue but did not verify if the medications were given, and the DON was unaware of the error. The facility failed to ensure medications were administered on time as per physician orders.
A facility failed to ensure that a resident's care plan included targeted behaviors to monitor the effectiveness of psychotropic medications. The resident was prescribed Bupropion, Quetiapine, and Sertraline, but the care plan lacked specific behavior monitoring. Interviews with staff revealed a lack of training and clarity on individualized behavior monitoring, and the facility's electronic medical record system did not update care plans with specific behaviors. This resulted in a generalized approach to monitoring, preventing adequate assessment of medication effectiveness.
A facility experienced an 8% medication error rate when an RN failed to administer medications according to physician orders. A resident with Peripheral Vascular Disease and Hypertension received incorrect doses of Hydrocortisone and Carvedilol, with the latter given without a meal and outside the prescribed time frame. The ADON confirmed these errors, highlighting the need for proper medication handling.
Two residents in a LTC facility experienced significant medication errors. One resident received Midodrine despite having a systolic blood pressure above the prescribed limit, resulting in multiple errors. Another resident did not receive nighttime medications, including insulin, as the medications were not signed out. The facility's policy requires medications to be administered safely and timely, but these incidents show a failure to adhere to prescribed parameters and timely administration.
A resident with chronic respiratory conditions was not offered a follow-up pneumococcal vaccine after becoming eligible, despite CDC recommendations. The facility's process for tracking vaccine eligibility, which involved checking the Wisconsin Immunization Registry every few months, failed to ensure timely vaccination.
Failure to Complete Comprehensive Wound Assessments and Timely Physician Notification
Penalty
Summary
A resident was admitted to the facility with a wound on her left abdomen, along with other medical conditions including rheumatoid arthritis, type 2 diabetes with polyneuropathy, and heart failure. Upon admission, the wound was noted to have exudate and odor, but the initial assessment was performed by an LPN, which is not in accordance with the Wisconsin Nurse Practice Act that requires an RN to conduct assessments. There was no evidence that an RN reviewed or signed off on the LPN's observation, nor was there documentation that a provider was notified about the wound odor at that time. Throughout the resident's stay, the facility failed to complete ongoing comprehensive wound assessments as required by professional standards and facility policy. Documentation was inconsistent and incomplete, lacking critical wound characteristics such as type, bed description, surrounding tissue appearance, drainage, and odor. The wound increased in size and developed a foul odor, but there was no timely notification to the physician regarding these changes. Multiple staff interviews confirmed that changes such as increased wound size, odor, and drainage should have prompted provider notification, but this did not occur. The resident's condition deteriorated, with the wound developing thick, green/brown drainage, increased pain, and redness. Eventually, the resident requested to be sent to the emergency department, where she was diagnosed with a wound infection and septic shock. Hospital records confirmed the presence of multiple organisms in the wound culture. The lack of comprehensive wound assessment, failure to follow professional standards, and delayed physician notification directly contributed to the resident's readmission to the hospital with a serious wound infection.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for multiple residents, as evidenced by direct observations and resident interviews. Several rooms were found to be unclean, with one resident's room containing dried substances, crumbs, and what staff identified as fecal matter on the outside of the toilet that had reportedly been present for over a month. Additional observations included trash bags containing dirty linen and personal protective equipment left on the floor, and floors with visible debris and dried spills. Residents reported that housekeeping did not clean their rooms regularly, with some stating their rooms were cleaned only once a week or less frequently. Staff interviews confirmed the lack of regular cleaning, with a CNA acknowledging that not all rooms could be cleaned daily and the Housekeeping Supervisor citing insufficient staffing to complete all necessary cleaning tasks. The facility's own policy required regular cleaning and disinfection of resident rooms, but this was not consistently followed. There was also a lack of systematic communication with residents regarding their housekeeping concerns, as the Housekeeping Supervisor did not participate in resident council meetings to address such issues.
Failure to Provide Timely and Accurate Pharmaceutical Services
Penalty
Summary
The facility failed to ensure the provision of pharmaceutical services to meet the needs of multiple residents, resulting in missed, delayed, or omitted medication doses. For several residents, medications were not administered as ordered due to various reasons, including the facility's internet being down, medications being unavailable, and untimely administration by nursing staff. Facility policies required medications to be administered in a safe and timely manner, within one hour of the prescribed time, and for medication errors to be documented and reported. However, these policies were not consistently followed. One resident with multiple sclerosis, convulsions, major depressive disorder, and vitamin D deficiency did not receive scheduled medications at two different times because the facility's internet was down, and staff did not utilize available contingency plans such as printed MARs or alternative internet access. Another resident with rhabdomyolysis and traumatic ischemia of muscle also missed a scheduled dose for the same reason. Interviews with the DON and ADON confirmed that these omissions were considered medication errors and that staff were not fully aware of or did not implement alternative procedures during the internet outage. Additional deficiencies included a resident with metabolic encephalopathy, sepsis, diabetes, epilepsy, and other conditions who missed multiple doses of critical medications over several days due to drug unavailability, despite the facility having a contingency supply. Another resident with end stage renal disease and epilepsy did not receive several medications after returning from a hospital stay because orders were not promptly renewed and medications were not available for an extended period. Furthermore, a resident reported regularly receiving medications late, and review of MARs and staff interviews confirmed that morning medications were administered well outside the required time frame, constituting medication errors. These events demonstrate failures in medication acquisition, timely administration, and adherence to facility policy.
Failure to Honor Resident's Dining Location Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's stated preference to eat meals in the dining room, as required by both facility policy and federal regulations regarding resident rights. The resident, who has a history of multiple sclerosis, cerebral infarction, major depressive disorder, muscle weakness, and heart failure, expressed her desire to eat in the dining room for social interaction and because she had no suitable place to eat in her room. Despite her care plan and meal tickets indicating her preference for dining room meals, staff did not consistently facilitate this choice. On the morning in question, the resident was not taken to the dining room for breakfast due to a delay in her scheduled shower, resulting in her receiving her meal in her room instead. Interviews with facility staff, including the CNA, Dietary Manager, and DON, confirmed that the resident's preference to eat in the dining room was known and documented. The DON acknowledged that it is the resident's right to choose where to eat and that staff should honor this choice. However, the failure to coordinate care and ensure the resident was clean and dressed in time for breakfast led to her not being able to exercise her right to dine in the dining room as she wished.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including Multiple Sclerosis, cerebral infarction, major depressive disorder, muscle weakness, and heart failure, was not provided with appropriate pressure ulcer prevention and care as outlined in facility policy and physician orders. The resident, identified as being at risk for pressure injuries, had a stage 2 pressure injury to the coccyx. The care plan and physician orders specified the use of a pulsating mattress, a pressure offloading cushion when up in a chair, and repositioning every 30 minutes. However, during the survey, the resident was observed sitting in a recliner without a cushion, and the specialty mattress was set to static rather than pulsate. Staff did not encourage or assist the resident to reposition during the nearly hour-long observation period. Further review revealed that the Resident Profile sheet used by CNAs to guide care did not include any pressure injury prevention interventions, despite these being present in the care plan and physician orders. Interviews with CNAs and the DON confirmed that the necessary interventions were not being followed, and the DON acknowledged that the resident's pressure injury prevention devices were not in place as required. The lack of implementation and communication of pressure injury prevention measures directly contributed to the deficiency.
Catheter Bag Placement Deficiency
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter was observed with their catheter tubing and drainage bag resting on the floor while seated in a recliner. The resident expressed concern about the care of their catheter tubing and drainage bag, noting a history of urinary tract infections. Facility policy, physician orders, and the resident's care plan all specify that catheter tubing and drainage bags should not touch the floor to prevent infection. During interviews, both a CNA and the Director of Nursing confirmed that catheter tubing and drainage bags should not be placed on the floor, and acknowledged that the observed situation was not in accordance with facility protocols. The deficiency was based on direct observation, resident interview, and review of relevant documentation, all of which indicated that the required standard of care for catheter management was not maintained for this resident.
Failure to Provide Behavioral Health Care and Services for Residents with SUD and Suicidal History
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to ensure residents received the highest practicable mental and psychosocial well-being. Specifically, the facility did not create comprehensive assessments or care plans to address a substance use disorder (SUD) for one resident and failed to address a history of suicidal ideations and attempts for another resident. The surveyor found that the facility did not have a substance abuse policy, and the care plans for both residents lacked goals, interventions, and monitoring related to their behavioral health needs. One resident with a documented SUD, including alcohol and cocaine abuse, was admitted with multiple related diagnoses such as alcohol-induced chronic pancreatitis and end-stage renal disease. Despite evidence of ongoing alcohol consumption, including the discovery of empty vodka bottles in the resident's room and a missed dialysis session, the facility did not develop or implement a care plan addressing the resident's substance use, triggers, or associated behaviors. The social worker was unaware of the resident's SUD and no referral to the facility's substance use program was made, as referrals were only initiated with a physician or NP order, not based on active diagnoses. Another resident with a history of conversion disorder, PTSD, personality disorder, and multiple suicide attempts was not provided with a care plan addressing suicidal ideations or attempts. The care plan did not include any goals, interventions, or monitoring for suicide risk, despite the resident's extensive history of attempts, including recent overdoses and self-harm. Staff interviews confirmed that such histories should be care planned to inform monitoring and interventions, but this was not done, and no precautions or monitoring were in place for the resident's behavioral health needs.
Failure to Prevent Significant Medication Errors Due to System and Supply Issues
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two residents not receiving their prescribed medications as ordered. For one resident with a diagnosis of unspecified convulsions and a risk for seizures, two critical seizure medications, Lamictal and Levetiracetam, were not administered as scheduled due to the facility's internet being down. Documentation on the Medication Administration Record (MAR) indicated the medications were not given, with the reason cited as 'no internet.' Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that missing a medication dose for this reason is considered a medication error, and that alternative methods for accessing the MAR, such as making paper copies or using management's cell phone hotspots, were not effectively communicated or implemented at the time of the incident. Another resident, admitted with multiple complex diagnoses including metabolic encephalopathy, sepsis, acute respiratory failure, type 2 diabetes, epilepsy, hypertension, kidney transplant status, and hypothyroidism, did not receive several ordered medications over multiple days. These included anticonvulsants (Lacosamide and Levetiracetam), insulin, and an immunosuppressant (Mycophenolate). The MAR showed multiple instances where medications were not administered, with reasons such as 'drug/item unavailable' or left blank, indicating omission. The DON confirmed that these omissions were medication errors and that staff should have accessed contingency medication supplies, which were available for at least some of the missed medications. Facility policies required medications to be administered in accordance with prescriber orders and within specified timeframes, and mandated that medication errors be documented and reported. The events described show that these policies were not followed, resulting in significant medication errors for both residents. The failures included lack of timely administration, inadequate communication of contingency procedures, and failure to utilize available medication supplies.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in the presence of flies and ants in multiple areas, including the dining area, hallways, and resident rooms. Observations included flies landing on a resident's leg and foot during an interview, as well as reports from several residents about persistent fly infestations in their rooms and throughout the facility. Some residents reported that flies landed on their food during mealtimes, and others mentioned having to use fly swatters or sticky strips to manage the problem themselves. Ant strips covered with ants were also observed in one resident's room. Residents with varying degrees of cognitive impairment and intact cognition voiced concerns about the ongoing pest issues, with some stating they had reported the problem to staff but had not seen any improvement. Maintenance staff acknowledged awareness of the fly problem and indicated that pest control services were provided on a scheduled basis, but could not confirm any specific plan in place to address the current infestation. Facility records and staff interviews confirmed that the pest control program was not effectively implemented to prevent or address the presence of pests as required by policy.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify and consult with a resident's physician after significant changes in the resident's condition. Specifically, a resident with type 2 diabetes mellitus had blood glucose readings above the ordered parameter of 350 on two occasions. The physician's orders clearly stated that if blood sugar was greater than 350, the nurse should administer 5 units of insulin and call the medical doctor. Despite this, there was no documentation in the resident's progress notes indicating that the physician had been contacted regarding these elevated blood sugar levels. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for the physician to be notified and for this notification to be charted each time the blood sugar exceeded the specified threshold. Review of the resident's records showed no such documentation at the time of the events. A late entry was made the following day, indicating that the provider was informed of the previous day's elevated readings, but this was not done immediately as required by the physician's orders and facility policy.
Failure to Immediately Report Suspected Misappropriation of Medication
Penalty
Summary
A deficiency occurred when an LPN failed to immediately report a suspicion of misappropriation of medication as required by facility policy and state law. The incident began when a Registered Nurse/Infection Preventionist (RN/IP) requested and took the keys to the medication cart from the LPN, accessed the cart, and later stated they had found what they were looking for. The LPN, suspecting that medication may have been taken, performed a count of the narcotic medications and found the count to be correct, but noted that there was no way to verify the count of other medications. Despite suspecting possible misappropriation, the LPN did not report the concern to the Nursing Home Administrator (NHA) or Director of Nursing (DON) as required by facility policy. During interviews, the LPN acknowledged awareness of the requirement to report suspicions of misappropriation to the DON or NHA but admitted not doing so. The NHA confirmed that staff are expected to immediately report such suspicions and that no report had been made by the LPN regarding this incident. Facility policies reviewed by the surveyor clearly state that any suspicion of misappropriation must be reported immediately to the administrator and appropriate authorities for investigation.
Failure to Provide and Document Required Showering Assistance
Penalty
Summary
The facility failed to provide and document regular showering assistance for a resident who required help with activities of daily living due to impaired mobility from osteoarthritis. According to the facility's own policy, showers are to be given to promote cleanliness, comfort, and to observe skin condition, with specific documentation required for each shower, including date, time, staff involved, skin assessment, and resident tolerance. The resident was scheduled to receive showers twice weekly, but only six showers were documented over a period in which 23 should have occurred. Interviews with the DON, medical records staff, and a CNA confirmed that showers were to be documented on paper forms and uploaded into the electronic medical record. However, there were significant gaps in the documentation, and the DON acknowledged that if a shower was not documented, it was considered not done. The lack of documentation and the inability to provide records for the majority of scheduled showers indicated that the facility did not consistently provide or record the required showering assistance for the resident.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Ensure Timely Physician Visits After Admission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was seen by a physician at the required intervals following admission. According to facility policy and OBRA regulations, a resident must be seen by a physician within 30 days of admission, then at least every 30 days for the first 90 days, and every 60 days thereafter. Record review and staff interview revealed that a resident admitted with diagnoses including cellulitis of the left lower limb, chronic venous insufficiency, and edema, and with moderate cognitive impairment, was only seen by a nurse practitioner shortly after admission. There was no documentation that the resident was seen by a physician within the required 30-day period after admission. During an interview, the DON confirmed that the only documented visit for the resident since admission was by a nurse practitioner, and acknowledged that the resident had not been seen by a physician as required by policy and regulation. This failure to ensure timely physician visits was identified through both record review and staff interview.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Follow Infection Control Protocols During Wound and Perineal Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as evidenced by staff not adhering to established hand hygiene and perineal care protocols for two residents. During wound care for a resident with cellulitis, venous insufficiency, and edema, an LPN removed gloves five times and applied new gloves without performing hand hygiene between glove changes, contrary to facility policy and standard infection control practices. Both the LPN and the Director of Nursing acknowledged that hand hygiene should have been performed after glove removal and before donning new gloves, but it was not done during the observed procedure. In a separate incident, a CNA performing perineal care for another resident used two washcloths for cleaning and rinsing, then placed the used washcloths back into the wash basin and the used hand towel onto the resident's bedside table next to personal items. The CNA confirmed that these items were contaminated after use and should not have been placed back into the basin or on the bedside table. The facility's infection preventionist also confirmed that contaminated items should not be returned to clean areas or surfaces, indicating a breach in infection control practices during perineal care.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions for multiple residents, resulting in deficiencies related to accident hazards and resident safety. One resident, who was identified as an elopement risk upon admission and had a history of wandering, was not provided with necessary interventions such as a Wanderguard or increased supervision. This resident was able to leave the facility unnoticed and was found walking down a busy street by a staff member on break. There was no documentation of a full assessment, vital signs, or follow-up monitoring after the resident was returned to the facility. Two residents who were identified as smokers did not have smoking assessments or care plans in place, despite facility policy requiring such evaluations upon admission. Staff interviews confirmed that smoking assessments and care plans were expected but not completed. Both residents were observed smoking on multiple occasions, and staff described informal processes for supervising smoking, but there was no formal documentation or individualized planning to address their safety needs related to smoking. Another resident who voiced suicidal ideations did not have a trauma assessment or care plan for suicidal ideations, and there was no documentation of notification to the DON, provider, or family. Staff interviews revealed inconsistent understanding of the required procedures following suicidal statements, and the resident was placed on 1:1 supervision without clear documentation or follow-up. Additionally, a resident at risk for falls did not have fall interventions in place, and fall interventions were not present on CNA care cards or the resident's Kardex, despite being listed in the care plan. Staff were unclear about the current fall interventions, and there was a lack of consistent documentation and implementation of fall prevention measures.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The lack of appropriate provision of food and fluids resulted in a failure to support the resident's overall health status.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents or staff involved, were not provided in the report. No further information about the circumstances or individuals affected was included.
Failure to Complete Annual CNA Evaluations and Required In-Service Education
Penalty
Summary
The facility failed to complete annual performance evaluations for all nurse aides and did not provide the required 12 hours of annual in-service education for several staff members. Record review showed that none of the five nurse aides selected for evaluation had performance reviews completed every 12 months as required by facility policy. Additionally, four out of five nurse aides did not complete the mandated 12 hours of continuing education within the year, with documented hours ranging from 8.5 to 10 out of the required 12. The facility also lacked a specific policy or procedure addressing the required in-service education for nurse aides. Interviews with the Nursing Home Administrator confirmed that the required annual evaluations and education hours were not completed for the staff in question. The administrator acknowledged that each CNA should have a current evaluation and at least 12 hours of annual education, but records did not support compliance with these requirements. The deficiency was identified through both record review and staff interviews, with specific examples cited for each staff member involved.
Failure to Maintain Required QAA Committee Membership and Meeting Frequency
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee with the required membership and meeting frequency as outlined in its own policy and federal regulations. Specifically, the QAA Committee did not consistently include the Medical Director, who is a required member, during meetings held in June 2024 and July 2025. Additionally, the committee did not meet at least quarterly as required, with two meetings over the last four quarters not occurring within the appropriate timeframe. Review of sign-in sheets confirmed the absence of the Medical Director at the specified meetings, and there was no documentation to support that the Medical Director was informed of the meeting content in a manner consistent with policy requirements. The Nursing Home Administrator confirmed these deficiencies during an interview, acknowledging both the absence of the Medical Director at the required meetings and the failure to meet the quarterly meeting schedule. The facility's QAPI policy specifies the necessary committee members and meeting frequency, but records and interviews demonstrated that these requirements were not met. This deficiency has the potential to affect all 48 residents residing in the facility.
Failure to Timely Report Abuse, Neglect, and Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property were reported to the appropriate authorities within the required timeframes. Specifically, three out of five reportable incidents were not reported as mandated. One resident eloped from the facility, and two separate resident-to-resident altercations occurred, but none of these incidents were reported to the State Agency as required by regulations. Interviews with staff revealed inconsistencies in training and knowledge regarding the reporting and management of resident-to-resident altercations. While a CNA indicated awareness of the need to deescalate and report such incidents immediately, an LPN stated she had not received recent training on this topic. An RN reported having received training and posted relevant materials at a nurses' station, but also noted that further education was planned. These findings indicate that the facility did not consistently follow established procedures for timely reporting of incidents involving potential abuse or neglect.
Inconsistent Staff Training on Resident-to-Resident Altercations
Penalty
Summary
Surveyor interviews revealed inconsistent staff training regarding resident-to-resident altercations. A CNA reported having received training on deescalating and reporting such incidents, while an LPN stated she had not received any recent training on this topic. The LPN described her intended response to future altercations, which included separating residents and redirecting them, but this was not based on formal training. An RN indicated she had received training in the previous months and referenced a flow sheet on resident altercations posted at a nurses station, as well as the use of a 24-hour board to communicate resident behaviors and incidents between shifts. The Nursing Home Administrator confirmed that all alleged violations should be thoroughly investigated.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and agreed to by the resident, and that proper care was given to those with feeding tubes.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for multiple residents, as required by facility policy and professional standards. For one resident with Alzheimer's disease, seizures, and intellectual disabilities, there was no documentation in the medical record regarding a significant change in condition and subsequent death. Although staff interviews confirmed that the resident experienced a decline, was assessed by nursing staff, and emergency services were called, none of these events or the resident's passing were recorded in the medical record. Another resident who expressed suicidal ideations did not have appropriate nursing documentation following the incident. While progress notes indicated the resident made statements about self-harm and staff redirected her, there was no evidence of follow-up or nursing assessment documented in the medical record, despite facility policy requiring such documentation for suicide threats. Interviews with facility leadership confirmed that nursing documentation was expected in these circumstances. Additionally, the facility failed to document a resident-to-resident altercation in both involved residents' medical records. While one resident's progress notes described the altercation and staff intervention, the other resident's record contained no documentation of the incident, contrary to facility policy requiring incident documentation for all involved parties. These omissions resulted in incomplete medical records that did not accurately reflect the care provided or the residents' conditions.
Failure to Ensure Safe Transfer and Documentation After Hoyer Lift Fall
Penalty
Summary
A resident with a history of acute respiratory failure and impaired physical mobility, who was assessed as cognitively intact, was involved in a transfer incident using a Hoyer lift. The care plan specified that two staff members and a Hoyer lift were required for transfers. During a transfer performed by a CNA and the Director of Nursing, the sling being used—brought with the resident upon readmission from the hospital—ripped, causing the resident to fall to the floor and strike her head. The resident was subsequently sent to the hospital, where no intracranial injuries or fractures were found. The incident was not documented in the electronic medical record, and there was uncertainty among staff regarding whether an incident report or progress note was completed. The facility's policy required the use of appropriate techniques and equipment to ensure resident safety, but the use of a potentially unsuitable sling and lack of documentation following the incident indicated a failure to follow established procedures. The administrator at the time of the survey was unable to locate any records or documentation related to the event.
Failure to Notify Hospice and Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify hospice and the resident's representative in a timely manner regarding a change in condition for one of the sampled residents, identified as R4. R4 experienced a change in her eating habits, which was not communicated to hospice or her representative. The facility's policy requires direct care staff to recognize and communicate significant changes in a resident's condition, such as a decrease in food intake, to the nurse. However, this protocol was not followed, leading to a delay in notifying the appropriate parties. R4 was admitted to the facility with diagnoses including senile degeneration of the brain, aphasia, and dysphagia, and was utilizing hospice services. Her care plan included monitoring food and fluid intake and notifying hospice of any changes in her condition. Despite this, R4's electronic medical record showed no meal intakes documented except for minimal amounts on specific dates. Staff reported that R4 had been unable to eat or drink for two to three days, but this information was not promptly communicated to hospice or her family member, who was her emergency contact. Interviews with facility staff revealed that there was a lack of communication regarding R4's condition. A Certified Occupational Therapy Assistant and a Certified Nurse Aide both noted R4's unusual refusal to eat, which was a significant change from her normal behavior. The Director of Nursing stated that hospice and family should be notified within a day if a resident is not eating or drinking, but questioned the accuracy of the information passed along by staff. Ultimately, hospice was only contacted after several days, and R4 was sent to the emergency room following the delayed notification.
Delayed Reporting of Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report a resident-to-resident abuse allegation within the required two-hour timeframe, as per their policy. The incident involved two residents, one with metabolic encephalopathy and the other with dementia and anxiety. The abuse was reported by a family member via email to the facility's former Admissions Director, who then informed the administration the following day. The incident was initially believed to involve a staff member, but upon investigation, it was found to be between two residents. The facility's policy requires immediate reporting of abuse allegations, defined as within two hours, but the report to the State Agency was delayed. The incident occurred when one resident allegedly backhanded another in the face and rammed her wheelchair into the other's wheelchair. The resident who reported the incident had moderately impaired cognition, while the alleged perpetrator had severely impaired cognition. Staff members, including CNAs, were informed of the incident on the night it occurred and reported it to the nurse on duty. However, the administration was not aware of the incident until the email was read the next day, leading to a delay in reporting to the State Agency. The Assistant Administrator was not involved in the initial reporting process and was unaware of the staff's immediate reporting to the nurse.
Inadequate Investigation of Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged resident-to-resident abuse incident involving two residents. The facility's policy requires that all allegations be thoroughly investigated, including interviewing all staff members who had contact with the residents during the period of the alleged incident. However, the investigation did not include interviews with staff who were on duty during the shift when the incident occurred. The Assistant Administrator confirmed that the investigation was not thorough and acknowledged that not all relevant staff were interviewed. The incident involved two residents, one with moderately impaired cognition and the other with severely impaired cognition. The alleged incident occurred when one resident reportedly backhanded the other in the face and rammed her wheelchair into the other's wheelchair. The resident who reported the incident informed the nurse on duty, who addressed the situation. However, the investigation did not verify if all potential witnesses, including a specific agency staff member, were contacted. Interviews conducted during the investigation revealed inconsistencies and gaps in the information gathered. Some staff members reported hearing about the incident secondhand, while others did not witness the event but were aware of the residents' behaviors. The Assistant Administrator admitted to limited involvement in the investigation and could not confirm if all necessary interviews were conducted. The facility's failure to interview all relevant staff and thoroughly document the investigation led to the deficiency.
Medication Administration Deficiency for a Resident
Penalty
Summary
The facility failed to administer medications as scheduled for a resident, identified as R3, who was reviewed for medication administration. R3's medications were documented as not being administered or being administered late on multiple occasions. The facility's policy requires medications to be administered within one hour of their prescribed time, but this was not adhered to. R3, who had diagnoses including pulmonary hypertension, hypertension, and localized edema, experienced late administration of several medications, including hydralazine, fexofenadine, liothyronine, losartan, torsemide, and folic acid, over the course of several days. R3 reported receiving medications late or not at all, recalling specific issues on certain dates where medications scheduled for 8:00 AM were administered as late as 12:30 PM. The resident also reported experiencing chest pain and needing to request nitroglycerin when blood pressure medications were not given on time. The Director of Nursing confirmed the late medication administrations and stated the expectation that medications should be administered within an hour of the scheduled time.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by a 64.28% error rate observed during a medication administration task. Surveyors noted 18 errors out of 28 medication opportunities, affecting three residents. The errors primarily involved administering medications more than an hour past their scheduled time, contrary to the facility's policy that medications should be administered within one hour of their prescribed time unless otherwise specified. Resident 10, who has multiple diagnoses including end-stage renal disease and hypertension, received her 8:00 AM medications at 9:09 AM. The delay was attributed to RN3, who was new to the facility and behind on her medication pass due to residents lining up and talking at the medication cart. Similarly, Resident 11, with diabetes and myopathy, received her 8:00 AM medications at 9:47 AM, after she had already finished breakfast. CNA1, who administered the medications, was observed giving insulin and a lidocaine patch without a breakfast tray present. Resident 12, diagnosed with heart failure and pulmonary hypertension, received her 8:00 AM medications at 10:10 AM, except for lorazepam and bupropion, which she refused. CNA1 reported starting late and being pulled to other tasks, contributing to the delay. Interviews with staff revealed issues such as lack of access to the facility's contingency supply, out-of-town pharmacy delays, and other tasks like falls and lab draws interfering with timely medication administration. The Director of Nursing confirmed the expectation for medications to be administered within the specified time frame, acknowledging the late administrations.
Failure to Monitor and Report Change in Condition Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care to prevent hospitalization, as per professional standards of practice. The resident, identified as R18, experienced a change in condition that was not fully assessed or monitored by the facility staff. Despite R18's history of congestive heart failure and other significant health issues, the facility did not complete necessary assessments or notify the physician of the resident's condition changes, including a significant weight gain and increased fatigue. R18 was readmitted to the facility with diagnoses including decompensated heart failure. The resident's weight increased by 12 pounds within a day, yet there was no documentation of the provider being updated or an assessment being completed regarding this weight gain. Additionally, the resident exhibited symptoms such as increased fatigue, elevated heart rate, increased respirations, and changes in oxygen needs, but these were not communicated to the physician in a timely manner. The facility's failure to act on these changes resulted in R18 being hospitalized with conditions including atrial flutter and acute decompensated heart failure. Interviews with facility staff, including the Nurse Practitioner and Director of Nursing, revealed that the facility's processes for monitoring and reporting changes in condition were not followed. The staff did not notify the provider of R18's weight gain or changes in vital signs, and the nurse responsible for R18's care did not attend the educational sessions provided by the facility on change in condition and physician notification. This lack of adherence to protocols and communication led to the resident's hospitalization, highlighting a deficiency in the facility's care practices.
Ice Machine Cleaning Deficiency
Penalty
Summary
The facility failed to ensure that the ice machine was cleaned and disinfected properly, which has the potential to affect all 56 residents. During an inspection, a surveyor observed a layer of black film on the inside lid of the ice machine. The facility's policy, last revised in January 2024, states that the ice machine should be cleaned and sanitized regularly, with maintenance responsible for deep cleaning it quarterly and as needed. However, there was confusion among staff about who was responsible for cleaning the ice machine, with the Dietary Manager unsure of the responsible party and the Maintenance Director unaware of any regular cleaning schedule or outside vendor involvement. The Maintenance Director admitted to cleaning the ice machine randomly when time allowed, indicating a lack of a set cleaning schedule. The Nursing Home Administrator mentioned plans to acquire new ice machines and expressed an expectation for the machines to be clean. Despite these expectations, the facility's failure to maintain a regular cleaning schedule for the ice machine resulted in the accumulation of a black film, which could pose health risks if ingested by residents.
Improper Garbage Disposal and Unsanitary Conditions
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed by a surveyor on multiple occasions. During an initial tour of the kitchen, the surveyor, along with the Dietary Manager (DM), observed various types of waste, including used gloves, wet cardboard boxes, food waste, stagnant water, cigarette butts, and packing peanuts, scattered on the ground near the main garbage dumpster. The DM was unsure of who was responsible for ensuring proper disposal and cleanup of garbage that fell on the ground. Interviews with the Maintenance Director and other maintenance staff revealed a lack of clarity and enforcement regarding responsibilities for maintaining cleanliness around the dumpster area. The Maintenance Director and staff expressed expectations that any staff member who noticed garbage outside the dumpster should pick it up, but there was no consistent follow-through. The Nursing Home Administrator also indicated an expectation for garbage to be picked up around the dumpster, but the area was not consistently maintained in a sanitary condition, potentially leading to pest issues.
Deficiency in Infection Prevention and Control Program
Penalty
Summary
The facility has failed to establish a comprehensive infection prevention and control program, which is crucial for maintaining a safe and sanitary environment and preventing the transmission of communicable diseases. The deficiency was identified during an interview and record review, where it was noted that the facility does not maintain a staff infection control line list for illnesses or infections other than COVID-19. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed that the facility only tracks COVID-19 cases among staff and does not have a comprehensive line list that includes other infections. The existing call-in log lacks critical information such as the last date worked, date symptoms started/resolved, return to work date, and type of infection, which are essential for ensuring that staff are appropriately excluded from work to prevent the spread of infections. Additionally, the facility's infection prevention and control policies have not been updated annually as required. Specific policies, such as the Legionella Water Management Program and the COVID-19 vaccination policies for residents and staff, have not been revised since 2022 and 2023, respectively. During the survey, the ADON/IP acknowledged that the policies should be reviewed annually and attempted to find more recent updates but was unable to do so. This lack of updated policies further indicates a deficiency in the facility's infection control program, potentially affecting all 56 residents in the facility.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents had access to call lights or a means to call staff for assistance, as observed in the cases of four residents. Resident 23, who is cognitively intact, was observed sitting in a Broda chair with the call light out of reach, attached to the bed behind them. Resident 25, also cognitively intact, reported instances where the call light was not within reach, necessitating calls to the main number or yelling for staff attention. Resident 17, who is moderately cognitively impaired, similarly reported difficulties in reaching the call light and having to yell for assistance due to immobility. Resident 19, who is cognitively intact, was observed in a wheelchair with a call light tied to the bed rail and out of reach. During the survey, a tourniquet was left on Resident 19's arm after a blood draw, and the call light was not accessible for the resident to request assistance. The Nursing Home Administrator acknowledged the expectation that call lights should be within reach when residents are in their rooms or bathrooms. The facility's failure to provide accessible call lights for these residents constitutes a deficiency in meeting their needs and preferences for assistance.
Inadequate Water Temperature Management
Penalty
Summary
The facility failed to provide a comfortable and homelike environment by not ensuring appropriate water temperatures for residents. This deficiency was observed in multiple instances, affecting several residents. Resident R38, who is cognitively intact and relies on his bathroom sink for washing due to his inability to use the shower, reported consistently cold water in his bathroom. The surveyor confirmed this by measuring the water temperature at 85.2°F, which is below the comfortable range. Other residents, including R13, R17, and R27, also reported issues with cold water during showers. R17, who is moderately cognitively impaired, experienced discomfort due to cold showers and reported this to a CNA. Similarly, R13 and R27, both of whom require assistance for showering, expressed dissatisfaction with the water temperature, noting that it often remains cold despite staff efforts to let it run for a while. Interviews with staff, including CNAs and maintenance personnel, revealed that the water temperature issue is ongoing and has been reported by residents. However, there seems to be a lack of consistent communication and resolution, as some staff were unaware of the problem or had not reported it to maintenance. The Maintenance Director was not informed of issues in certain areas, indicating a breakdown in reporting and addressing the water temperature concerns effectively.
Failure to Notify Physicians of Critical Changes
Penalty
Summary
The facility failed to immediately consult with the resident's physician when there was a need to alter treatment for two residents. For one resident, identified as R49, the facility did not notify the provider of a positive urine culture and sensitivity result, which delayed the treatment decision. The urine culture report, indicating the presence of Klebsiella pneumoniae and Pseudomonas aeruginosa, was received on a holiday, and the nurse practitioner was not informed until several days later. The Director of Nursing acknowledged that the resident had not been treated for the positive culture and that the provider should have been contacted sooner. In another case, a resident identified as R18 missed nighttime medications, and the primary physician was not notified of this occurrence. The resident, who was cognitively intact, had diagnoses including heart failure, vascular disease, diabetes, and respiratory failure. The Registered Nurse who discovered the missed medications did not remember notifying the Director of Nursing and confirmed that the primary physician was not informed. The facility's policy on lab and diagnostic test results requires prompt physician notification in situations where lab results are abnormal or when a resident's clinical status is unstable. The policy also specifies that direct voice communication with the physician is preferred for immediate notifications. In both cases, the facility did not adhere to its policy, resulting in a delay in treatment for R49 and a lack of physician notification for R18's missed medications.
Failure to Implement Comprehensive Care Plan for Anticoagulant Monitoring
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was taking Eliquis, an anticoagulant medication. The care plan did not address the need for monitoring side effects such as bruising or bleeding, which are known risks associated with the medication. Despite the facility's policy requiring care plans to include measurable objectives and reflect recognized standards of practice, the resident's care plan lacked any mention of the anticoagulant therapy or the necessary monitoring for its side effects. The resident in question had a history of multiple falls and severe cognitive impairment, requiring staff assistance for daily activities. The resident's physician had prescribed Eliquis for atrial fibrillation, but the care plan did not reflect this treatment or the associated monitoring needs. Interviews with facility staff, including a registered nurse and the director of nursing, revealed that while staff were aware of the need to monitor for side effects, this was not documented in the resident's care plan or medication administration records.
Failure to Implement Repositioning Plan Leads to Pressure Injury
Penalty
Summary
The facility failed to ensure proper care to prevent the development of pressure injuries for a resident identified as being at risk. The resident, who was admitted with multiple diagnoses including malignant neoplasm of the colon, type 2 diabetes, and hemiplegia, was assessed to be at risk for pressure injuries. Despite this assessment, the facility did not implement a repositioning plan as required by their policy. The resident's care plan mentioned a repositioning schedule for comfort and offloading, but no specific documentation of such a schedule was found in the resident's medical record. The resident, who is dependent on staff for repositioning, developed a new wound on the left calf, which was observed by an occupational therapist. The wound was described as a circular dark purple area with a scabbed center, indicating a pressure injury. Interviews with the resident revealed that staff did not regularly reposition him unless he used the call light to request assistance. The resident also mentioned that a pillow was placed under his legs in the recliner only after the wound developed, suggesting inadequate preventive measures were in place prior to the injury. Further interviews with facility staff, including a CNA and the DON, confirmed that the resident did not have a regular repositioning schedule. The DON stated that the root cause of the wound was determined to be the urinary catheter tubing sitting under the resident's leg while in the recliner. Despite the DON's assertion that the resident needed repositioning every 2-3 hours, there was no evidence of a consistent repositioning schedule being followed, contributing to the development of the pressure injury.
Failure to Monitor Nutritional Status and Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R49, maintained acceptable nutritional status and weight, which was a deficiency identified by surveyors. R49, who was at risk for malnutrition and had experienced weight loss, was not adequately monitored for meal intake. The facility's policy required monitoring of resident weights and meal intakes, but R49's meal intake was not consistently documented, and significant weight loss was not addressed in a timely manner. R49 was admitted with multiple diagnoses, including colon cancer, diabetes, and malnutrition, and was on a low fiber diet with specific dietary instructions. Despite these conditions, R49 experienced a weight loss of 26 pounds, or 10.68%, over three months, which was not reviewed until June 18, 2024. The facility's records showed inconsistent documentation of R49's meal intake, with only 20 meals charted out of a possible 246 over 82 days, indicating a lack of proper monitoring and documentation. Interviews with facility staff, including the Dietary Manager and Director of Nursing, revealed communication gaps and unclear responsibilities regarding dietary orders and documentation of meal intake. The Registered Dietician noted limited documentation of R49's meal and supplement consumption, and the Dietary Manager confirmed that R49 often refused the main meal and had specific meal preferences. The Director of Nursing acknowledged that CNAs were responsible for documenting resident intake, but this was not consistently done, contributing to the oversight of R49's nutritional needs.
Failure to Administer Scheduled Medications
Penalty
Summary
The facility failed to ensure that all residents received their scheduled medications on time as per physician orders, specifically affecting one resident. The resident, who was cognitively intact and had a history of heart failure, vascular disease, diabetes, and respiratory failure, did not receive their nighttime medications on a specified date. The medications included Lantus Solostar Insulin, Dicloxacillin, Eliquis, Fluticasone Propionate, Lipitor, Metoprolol Succinate, Potassium Chloride, Singulair, and Symbicort. The medications were not administered as the documentation did not support that vital signs were completed by the PM shift, and this was noted in the Medication Administration Record (MAR) the following day. The issue was discovered by an RN who documented the lack of administration on the MAR but did not verify with the previous shift if the medications were given. The Director of Nursing (DON) was unaware of the missed medications and indicated that if medications are not signed out, it means they were not given, classifying this as a medication error. The Nursing Home Administrator acknowledged the concern, emphasizing the importance of signing out medications on the MAR to confirm administration. The failure to administer medications as scheduled was identified as a deficiency by the surveyors.
Failure to Monitor Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to ensure that drug regimens were free of unnecessary psychotropic medications and that a resident taking such medication had a care plan that included targeted behaviors. Specifically, Resident R11 was prescribed Bupropion, Quetiapine, and Sertraline for mood disorders, but the care plan did not include behavior monitoring to assess the effectiveness of these medications. The facility's policy on psychotropic medication use requires that residents not receive medications that are not clinically indicated and that there be adequate monitoring for efficacy and adverse consequences. However, the care plan for R11 lacked specific behaviors to monitor, which is crucial for determining the effectiveness of the prescribed medications. Interviews with facility staff revealed a lack of clarity and training regarding behavior monitoring for residents on psychotropic medications. Certified Nursing Assistants (CNAs) reported relying on report sheets and care cards for information on behaviors to monitor, but these documents did not contain specific behaviors for R11. Additionally, the CNAs had not received training on individualized behavior monitoring. The Registered Nurse (RN) and Director of Nursing (DON) acknowledged that the targeted behaviors listed in the Treatment Administration Record (TAR) were not specific to R11 and that the care plan should have been updated to reflect individualized behaviors. The deficiency was further highlighted by the fact that the facility's electronic medical record system did not pull individualized behaviors into the care plan, as confirmed by the DON. This oversight resulted in a generalized approach to behavior monitoring, which did not account for the specific needs of R11. The lack of individualized behavior monitoring and documentation meant that the facility could not adequately assess the effectiveness of the psychotropic medications prescribed to R11, thereby failing to comply with their own policy and regulatory requirements.
Medication Administration Errors Result in 8% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during a medication pass task. This deficiency involved Registered Nurse (RN) D, who did not administer medications to Resident R46 according to the physician's orders. Specifically, RN D incorrectly administered Hydrocortisone by breaking a 10 mg tablet in half instead of using the prescribed 5 mg tablet for the 2 PM dose. Additionally, RN D administered Carvedilol without providing a snack or meal, as required by the medication's instructions, and did so outside the acceptable time frame of one hour before or after the scheduled time. Resident R46, who has a diagnosis of Peripheral Vascular Disease and Hypertension, was affected by these medication errors. The physician's orders specified that Hydrocortisone should be administered as 10 mg at 8 AM and 5 mg at 2 PM, while Carvedilol should be given twice daily with meals. The Assistant Director of Nursing (ADON) C confirmed these errors, noting that the pharmacy should have provided the correct tablet strength and that RN D should not have split the tablet. ADON C acknowledged these actions as medication errors.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the cases of two residents, R7 and R18. R7, who has multiple medical conditions including Multiple Sclerosis and Autonomic Dysreflexia, was prescribed Midodrine to be administered three times a day with the instruction to hold the medication if the systolic blood pressure exceeded 130. Despite this, the medication was administered on multiple occasions when R7's systolic blood pressure was above the specified limit, resulting in six significant medication errors. The errors were observed and confirmed by both the resident and the nursing staff, indicating a failure in adhering to the prescribed parameters for medication administration. R18, who has diagnoses including heart failure and diabetes, did not receive nighttime medications, including insulin, on a specific date. The MAR indicated that the medications were not signed out, and the RN who discovered the omission did not verify whether the medications were administered. The DON was unaware of the omission, and it was confirmed that the medications were not given, constituting a medication error. The failure to administer the prescribed insulin and other nighttime medications was acknowledged by the nursing home administrator and the DON. The facility's policy on administering medications requires that medications be given in a safe and timely manner, as prescribed, and within one hour of the scheduled time. However, the incidents involving R7 and R18 demonstrate a deviation from this policy, with medications being administered outside of the ordered parameters and not being administered at all. The staff involved acknowledged the errors, and the facility's leadership recognized the deficiencies in medication administration practices, which were identified during the surveyor's investigation.
Failure to Administer Follow-up Pneumococcal Vaccine
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures for ensuring that residents receive appropriate pneumococcal vaccinations. Specifically, the facility did not offer a resident, identified as R41, the necessary follow-up pneumococcal vaccine after they became eligible. R41 had received the Pneumococcal 23 vaccine on July 5, 2022, and according to CDC recommendations, should have been offered a dose of the Pneumococcal 15 or Pneumococcal 20 vaccine at least one year later. However, the facility did not offer this subsequent vaccination, and there was no documentation indicating that the resident received or declined the additional vaccine. The deficiency was identified during a surveyor's review of R41's immunization record and the Wisconsin Immunization Registry (WIR) report, which confirmed the absence of any further pneumococcal vaccinations after the initial dose. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) acknowledged the oversight and indicated that the current process for tracking vaccine eligibility involved checking the WIR every few months. This process failed to ensure timely vaccination for R41, who had chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease, and Atrial Fibrillation, conditions that necessitate vigilant immunization practices.
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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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