Lincoln Park Nursing And Rehab Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Racine, Wisconsin.
- Location
- 1700 C A Becker Dr, Racine, Wisconsin 53406
- CMS Provider Number
- 525061
- Inspections on file
- 29
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Lincoln Park Nursing And Rehab Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, right‑sided hemiplegia, incontinence, and high fall‑risk score was care‑planned only to have staff "anticipate and meet needs," despite the facility’s fall‑prevention program requiring more detailed interventions for high‑risk residents. The admission MDS documented dependence for rolling in bed, while an ADL care plan simultaneously described the resident as using enabler bars and an unspecified assistive device for bed mobility; these devices were not actually present on the bed at the time of the incident. The resident was on an air mattress and anticoagulants, and the air mattress was later identified as a predisposing factor but was not added to the care plan until after the fall. During care, the resident rolled or fell from the bed and was found on the floor; hospital records documented that the resident had been rolled for hygiene and subsequently sustained a brain bleed. Surveyors determined that the facility did not adequately assess and care‑plan the resident’s multiple fall‑risk factors or implement appropriate fall‑prevention interventions before the fall with major injury.
Surveyors found that the facility failed to promptly and comprehensively assess and treat pressure injuries for three residents on admission and readmission. One resident was admitted with a Stage 3 coccyx/buttocks pressure injury that was only minimally described, with no detailed wound characteristics documented, and no provider order for treatment obtained until two days later, with treatment not documented until the third day. Another resident with a chronic Stage 4 left gluteal fold ulcer had multiple hospital readmissions where staff documented only the wound’s location on the initial nursing evaluation, and comprehensive RN wound assessments were delayed by one to four days each time. A third resident at high risk for skin breakdown developed a sacral pressure injury that worsened significantly; after a hospital stay, this resident was readmitted with an unstageable sacral wound and a treatment order, but no comprehensive wound assessment was completed on the day of readmission, and the first detailed evaluation days later showed substantial deterioration. Interviews with the DON and wound staff confirmed that initial wound assessments and provider orders were often delayed or incomplete, contrary to facility policy requiring prompt, systematic pressure injury assessment and management.
Nursing staff failed to follow infection prevention protocols during medication administration, including placing medications and medical devices on unclean surfaces, not disinfecting shared equipment between uses, and not performing hand hygiene after glove removal. These lapses occurred while caring for multiple residents with chronic conditions such as diabetes and heart failure, and were confirmed by staff interviews and direct observation.
A resident with multiple serious health conditions did not receive two doses of their prescribed medications, carvedilol and tramadol, despite these being available in contingency stock. Instead, a dose of Eliquis, which was not ordered for the resident, was dispensed from the AMDS by an LPN. Facility policy requires medications to be administered as ordered and only prescribed medications to be dispensed, but these protocols were not followed. The DON and NHA confirmed that the physician should have been contacted for clarification, but this did not occur.
Two residents with severe cognitive impairment and behavioral issues were involved in multiple altercations, with one resident physically assaulting another on two occasions, including an incident where a wet floor sign was used as a weapon, resulting in a subdural hematoma and ICU admission. Despite known histories of aggression and wandering, staff were unable to effectively redirect or separate the residents, and care plan interventions were either delayed or ineffective, leading to a finding of Immediate Jeopardy.
The facility did not properly assess or address the behavioral and psychosocial needs of several residents with dementia and psychiatric disorders, failing to obtain critical background information from previous care settings and family, and not developing individualized care plans or interventions. This led to repeated aggressive incidents between residents, including physical altercations resulting in injury and hospitalization, and left staff unprepared to manage complex behaviors.
An allegation of one resident hitting and pinching another was not properly reported to law enforcement, despite facility records stating otherwise. No documentation or evidence was found to confirm that police were contacted, and the police department reported no calls from the facility during the relevant period.
Two residents' care plans were not updated or individualized after a resident-to-resident altercation, and interventions discussed by staff were not documented in the care plans. Additionally, there were inconsistencies between the care plans and smoking risk assessments for both residents, with conflicting information about supervision and storage of smoking materials. These deficiencies occurred despite facility policy requiring care plan updates after significant incidents.
A resident with multiple medical conditions and cognitive intactness refused showers for an extended period due to the shower room being too cold, a concern communicated to staff but not addressed with reasonable accommodations. Staff and maintenance were aware of the issue, but no interventions were implemented to help the resident stay warm during showers, resulting in the resident receiving only one bed bath in 30 days.
A resident with multiple medical conditions and cognitive intactness reported to two LPNs that staff were being rough with him during care, particularly due to knee pain. Despite facility policy requiring immediate reporting of such allegations, neither LPN reported the concern to the DON or Administrator, and the incident was not communicated to the state agency. The DON and Administrator confirmed they were unaware of the complaint, resulting in a failure to investigate or report the alleged mistreatment.
The facility did not investigate or thoroughly investigate in a timely manner two separate incidents: a resident's repeated complaints of staff being rough during care were not reported or investigated by LPNs, and a resident-to-resident altercation resulting in injury lacked a comprehensive investigation, witness statements, and care plan updates, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions did not have tubigrips applied as ordered in the care plan and physician orders, despite documentation indicating otherwise. Surveyors observed the resident without tubigrips on several occasions, and staff confirmed the expectation to follow the care plan, resulting in a deficiency for not providing care according to orders.
A resident with a right hand contracture and hemiplegia was not consistently provided with the recommended hand splint to maintain range of motion, despite occupational therapy and medical recommendations. The care plan did not include current interventions for splint use, and staff failed to document or address refusals or assist the resident with splint application, resulting in the resident being repeatedly observed without the splint.
A resident with an ostomy did not receive the correct supplies or care as ordered, resulting in the use of paper towels and washcloths in place of proper ostomy equipment. Staff interviews revealed confusion about supply ordering and a lack of stock, while observations confirmed the resident experienced leakage and discomfort due to inadequate supplies.
A registered nurse was observed dispensing medications to a resident by touching pills with bare hands, contrary to facility infection control policy requiring hand hygiene and glove use during medication administration. The administrator confirmed this was not proper medication handling.
The facility did not have a qualified Director of Food and Nutrition Services for its 83 residents. The Dietary Manager (DM) lacked education in food services and was unaware of the certification requirement. The DM, in the role for about a year, was preparing to take the Managerial ServSafe certification exam. The Administrator was unsure of the DM's certification status but confirmed the DM's upcoming exam.
The facility failed to provide written transfer notices to four residents and/or their POAs, relying instead on verbal communication. This deficiency was identified through record reviews and interviews, revealing a lack of compliance with the facility's Transfer and Discharge Guideline policy.
The facility failed to provide written bed hold notices to residents or their representatives upon hospital transfer, as required by policy. Four residents were transferred without receiving the necessary documentation, leading to potential confusion. Interviews confirmed that only verbal notices were given, and the DON was unfamiliar with the regulations.
The facility failed to serve food at a palatable temperature, affecting several residents. Observations showed significant temperature drops from preparation to service, with residents reporting cold and unappetizing meals. An LPN confirmed the food was difficult to chew and bland. The Dietary Manager was unaware of current issues, despite past concerns, and the DON expected better quality, indicating a lapse in adherence to food handling policies.
A resident was found with medications at their bedside without an assessment for self-administration. The resident, who was cognitively intact, had Fluticasone and saline nasal spray, and generic Sudafed pills, but no physician orders or care plan documentation for self-administration. The facility's policy requires an evaluation by a licensed nurse, which was not conducted, leading to the deficiency.
The facility failed to properly reconcile, transcribe, and administer medications for three residents, leading to potential adverse health outcomes. One resident's new medication orders were delayed, another's antidepressant was omitted from the MAR, and a third received an incorrect aspirin dose and missed insulin. These incidents highlight failures in medication administration and reconciliation processes.
A resident with a surgical amputation did not receive ordered wound care on two consecutive days, as documented in the TAR. The WCRN provided care during weekdays, while nursing staff were responsible on weekends. The resident reportedly refused care if not provided by preferred nurses, but staff failed to document refusals or reapproach the resident, leading to a deficiency in care.
The facility failed to follow physician orders for oxygen and CPAP treatment for two residents. One resident received oxygen at 5 LPM instead of the ordered 3 LPM, and another resident used a CPAP without a current physician's order. Staff confirmed these discrepancies, highlighting a lack of adherence to prescribed treatments.
A facility failed to ensure ongoing pre- and post-dialysis communication for a resident with end-stage renal disease receiving dialysis three times a week. Despite the care plan and physician orders, there were no completed communication forms in the resident's records. Staff interviews revealed a lack of established communication processes with the dialysis center, contrary to the facility's policy requiring written communication forms.
A long-term care facility failed to administer medications as ordered for four residents, leading to missed doses and delays. One resident with anemia did not receive a retacrit injection on time due to a lack of lab result confirmation. Another resident with rheumatoid arthritis missed adalimumab doses due to refill process issues. A third resident did not receive glucosamine-chondroitin due to order confusion. Lastly, a resident experienced delays in receiving carbidopa-levodopa due to insurance and communication issues.
The facility failed to maintain a medication error rate below five percent, resulting in a 12.9 percent error rate. Two residents were affected: one did not receive glucosamine-chondroitin due to a missing dose specification, and another did not receive carbidopa-levodopa due to insurance and delivery issues. The facility used an immediate release form as a temporary substitution.
The facility failed to secure a medication cart on Unit 3 Hall, leaving it unlocked and unattended, which was acknowledged by an LPN. Additionally, a resident's medications were left unsecured at the bedside while the resident was asleep, contrary to facility policy. The DON confirmed these actions were against basic nursing expectations and facility policies.
A facility failed to follow infection prevention standards during a medication pass, as an RN did not disinfect a shared glucometer between two residents with diabetes. The RN also neglected hand hygiene protocols and had personal food items on the medication cart, contrary to facility policy. The DON confirmed these lapses in procedure.
A resident with severe cognitive impairment was injured by another resident after a wheelchair incident. The facility failed to update the care plan for the aggressive resident, despite the incident being reported and witnessed by staff.
The facility failed to report an allegation of resident-to-resident abuse to the state agency. A resident with moderately impaired cognition reported being slapped by another resident with intact cognition. The incident was not documented in the electronic medical records or incident report. The facility's decision not to report was based on an algorithm indicating no harm, despite the resident's consistent story and the facility's policy requiring reporting within two hours if abuse was involved.
The facility failed to update care plans for a resident with aggressive behavior, another with alcohol use and disruptive behaviors, and a third with a change from a Foley to a suprapubic catheter. Despite incidents and changes in condition, care plans lacked necessary interventions and updates, as confirmed by staff interviews and policy reviews.
Failure to Implement Adequate Fall-Prevention Interventions for High-Risk Resident on Air Mattress
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an identified high‑risk resident had appropriate fall‑prevention interventions in place, resulting in a fall from bed with major injury. The resident had a history of cerebral infarction with right‑sided hemiplegia and aphasia, was severely cognitively impaired, and was dependent on staff for ADLs, including rolling in bed and transfers, per the admission MDS dated 5/10/25. The resident was always incontinent of bowel and bladder and had decreased mobility requiring assistance for repositioning, as documented in the CAA for pressure injuries. A fall risk evaluation dated 5/8/25 scored the resident at 7, which the facility defined as high risk for falls. Despite these identified risk factors, the fall care plan initiated 5/7/25 for risk of falls related to right hemiparesis, impaired mobility, and general weakness contained only the intervention to "anticipate and meet the resident’s needs" and did not include specific fall‑prevention measures. The resident’s ADL care plan for bed mobility, initiated 5/8/25, documented that the resident was an assist of one with turning and repositioning in bed and that the resident used enabler bars and an unspecified assistive device to maximize independence with turning and repositioning. However, the admission MDS indicated the resident was dependent on staff for rolling in bed, and other mobility tasks were not attempted due to medical condition or safety concerns, creating contradictory assessments regarding the resident’s bed mobility and the appropriateness of enabler‑type interventions. The surveyor noted that the interventions listed on the ADL care plan, including enabler bars and an assistive device, were not actually present on the bed according to the post‑fall investigation. Additionally, the resident was on an air mattress, which was identified in the fall investigation as a predisposing situational factor, but this air mattress was not added to the resident’s care plan until after the fall. On the date of the incident, staff documentation indicated that a nurse was called to the room by a CNA and found the resident lying on the floor next to the bed. The resident was unable to describe the fall, and the event was documented as unwitnessed, with no environmental hazards identified and no injuries initially observed. The hospital record later documented that the resident had been rolled onto her side for hygiene purposes and fell out of bed, and that the resident was on aspirin and Eliquis at the time. The facility’s fall detail and investigation forms listed multiple predisposing physiological factors, including confusion, difficulty with communication, gait imbalance, incontinence, weakness, antianxiety use, and the presence of a specialty bed, but the surveyor noted these risk factors had not been assessed or addressed in the care plan prior to the fall. The resident was subsequently found at the hospital to have a left subacute infarct of the left parietal and frontal lobe with petechial hemorrhage along the acute infarct (brain bleed). The surveyor concluded that the facility did not adequately assess the resident’s various risk factors or implement appropriate interventions to prevent a fall with major injury. The facility’s own fall prevention program, dated 1/3/23, required implementation of universal environmental interventions for low/moderate risk residents and additional individualized interventions for high‑risk residents, including assistive devices, increased rounding, low bed, alternate call systems, and scheduled toileting or ambulation. Despite this written program, the resident’s care plan prior to the fall did not reflect these high‑risk protocols, and there was no documentation of specific fall‑prevention strategies tailored to the resident’s identified high fall risk, right‑sided weakness, severe cognitive impairment, anticoagulant use, and use of an air mattress. The surveyor also noted inconsistencies between the facility’s internal investigation narrative, which stated that appropriate interventions were in place and that the incident was not due to noncompliance, and the clinical and care‑planning record, which showed missing and contradictory interventions and an incomplete assessment of fall risk factors before the fall occurred.
Delayed and Incomplete Pressure Injury Assessment and Treatment on Admission and Readmission
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and comprehensive pressure injury assessment and treatment for three residents with existing or potential pressure ulcers. For one resident admitted with a documented Stage 3 coccyx/buttocks pressure injury, the admission assessment noted only basic measurements and staging without detailed wound characteristics such as tissue type, exudate, odor, or pain. There were no hospital discharge instructions or treatment orders for a coccyx wound, and the facility did not obtain a physician order for wound treatment until two days after admission. Treatment was not documented as being provided until three days after admission, despite the facility’s policy requiring prompt assessment and treatment and full-body skin assessments with detailed wound documentation upon admission/readmission. A second resident with a known Stage 4 pressure injury to the left gluteal fold experienced multiple hospitalizations and readmissions over the review period. On several readmissions, the initial Nursing Evaluation forms documented only the presence and location of a decubitus ulcer or wound to the left buttock/gluteal fold, without measurements or comprehensive wound characteristics. Comprehensive RN wound assessments were delayed by one to four days after each readmission. The DON acknowledged that the process in place had nurses document only wound location and defer etiology and full assessment to the wound nurse and wound physician during weekly rounds, resulting in gaps in same-day readmission assessments and incomplete documentation of the wound’s progression. A third resident with significant functional impairment, incontinence, and identified risk for pressure ulcer development developed a new coccyx/sacrum pressure injury that progressed from a deep tissue injury to an unstageable and then Stage 4 wound. After a hospitalization for a fall, the resident was readmitted with an unstageable sacral pressure injury and an order for Medihoney with foam dressing. However, there was no comprehensive wound assessment documented on the day of readmission; the first detailed skin and wound evaluation was not completed until several days later. That evaluation documented a substantially deteriorated sacral wound with increased size, 100% slough, and denuded, erythematous surrounding tissue. Subsequent wound physician assessments described further deterioration, necrosis, and the need for increased level of care and hospital evaluation. The DON could not explain why a comprehensive assessment was not completed on the readmission date and attributed the resident’s wound deterioration in part to poor appetite and the family’s decision against tube feeding. Across these three cases, surveyors found that the facility did not follow its own pressure injury prevention and management policy requiring a systematic approach with prompt assessment, detailed documentation, and timely treatment. Admission and readmission assessments were incomplete or delayed, physician treatment orders were not obtained promptly in at least one case, and comprehensive RN or wound nurse assessments were deferred for days after residents returned from the hospital with significant pressure injuries. The DON and wound staff interviews confirmed that wounds were sometimes managed based on existing dressings without immediate provider orders and that the system for initial wound assessment on readmission was not functioning as intended.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
Surveyors observed that nursing staff failed to maintain proper infection prevention practices during medication administration for six residents. Specifically, two nurses were seen placing medications and medical devices, such as glucometers and insulin pens, on unclean surfaces without disinfecting them before or after use. Shared equipment, including blood pressure cuffs and pulse oximeters, was not cleaned between residents, and personal protective equipment (PPE) was not appropriately donned or doffed between resident care activities. In several instances, hand hygiene was not performed after glove removal, and items were returned to the medication cart without proper disinfection or adherence to required contact times for germicidal wipes. The residents involved had significant medical conditions, including diabetes, heart failure, and asthma, which required frequent monitoring and medication administration. During medication passes, nurses were observed placing glucometers and insulin pens on bare surfaces of medication carts and bedside tables, both in common areas and resident rooms. In multiple cases, nurses failed to sanitize equipment between uses and did not follow hand hygiene protocols after removing gloves or before handling medications and devices for different residents. These actions were confirmed by staff interviews, where nurses acknowledged not following established infection control protocols due to being rushed or distracted by other duties. Facility policies and CDC guidelines reviewed by surveyors clearly required cleaning and disinfecting shared equipment before and after each use, performing hand hygiene according to established procedures, and using PPE appropriately. The Director of Nursing confirmed that staff were expected to adhere to these protocols. However, direct observations and staff admissions demonstrated that these standards were not consistently followed during the observed medication administration processes.
Failure to Administer Ordered Medications and Unordered Medication Dispensed
Penalty
Summary
A deficiency occurred when a resident did not receive two doses of their ordered medications, carvedilol and tramadol, as documented in the Medication Administration Record (MAR) for a specific morning. The nurse's note indicated that these medications were not administered due to awaiting pharmacy delivery, despite the facility having both medications available in contingency stock. The carvedilol available was of a lower dose, but two tablets could have been given to achieve the prescribed dosage, and the physician was not contacted for clarification. Additionally, the facility's Automated Medication Dispensing System (AMDS) records showed that Eliquis, a medication not prescribed for the resident, was dispensed to them by an LPN, who later did not recall this action. The resident had multiple diagnoses, including a right fibula fracture, cardiomyopathy, heart failure, and kidney failure. The facility's policies require medications to be administered according to physician orders and that only prescribed medications be removed from the AMDS. The surveyor found that the resident's prescribed aspirin had a major interaction with Eliquis, and three other medications had moderate interactions, according to a drug interaction checker. The facility's leadership acknowledged that the physician should have been contacted regarding the medication issue, but this was not done.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in multiple incidents of resident-to-resident altercations. One resident, with a history of severe cognitive impairment, Alzheimer's Disease, and substance abuse, was physically assaulted on two separate occasions by another resident known for physical aggression, severe cognitive impairment, and behavioral disturbances. The first incident involved the aggressive resident striking the other resident in the arm twice in a common area, despite staff attempts to redirect both individuals. The second incident escalated when the same aggressive resident struck the other in the back and later in the head with a wet floor sign, causing a subdural hematoma and necessitating an ICU stay. The facility's records indicate that both residents had documented histories of behavioral issues, including wandering, aggression, and refusal of care or medications. Care plans for both residents included interventions such as redirection, monitoring, and providing calm environments, but these were either initiated after the incidents or were not effective in preventing the altercations. Staff statements and facility self-reports confirm that both residents were known to wander and become agitated, and that staff were unable to successfully redirect or separate them before the physical altercations occurred. Additionally, the aggressive resident had a pattern of refusing prescribed psychotropic and other medications, which was known to the facility and documented in the medical record. The facility's policy required immediate investigation and protective measures in cases of abuse, as well as ongoing assessment and care planning for residents with behaviors that might lead to conflict. However, the facility did not prevent the repeated physical abuse, nor did it implement effective interventions to separate or supervise the residents in a manner that would have prevented further harm. The failure to protect residents from abuse resulted in significant injury and constituted a finding of Immediate Jeopardy.
Failure to Provide Medically-Related Social Services and Behavioral Interventions
Penalty
Summary
The facility failed to provide medically-related social services to help residents achieve the highest practicable physical, mental, and psychosocial well-being, as evidenced by the lack of proper assessment, care planning, and intervention for four residents with significant behavioral and psychosocial needs. For two residents with severe cognitive impairment and behavioral disturbances, the facility did not obtain or utilize pertinent information from previous care settings, family, or hospice providers prior to admission. This resulted in the absence of individualized psychosocial interventions and inadequate care plans to address their complex behaviors, including aggression, wandering, and refusal of care. The facility also did not assess or address the trauma backgrounds or social histories of these residents, which were relevant to their care and management. The report details that one resident with Alzheimer's disease, alcohol abuse, and PTSD exhibited aggressive and wandering behaviors upon admission. The facility did not reach out to the resident's previous assisted living facility, hospice, or activated power of attorney to gather essential background information and effective behavioral interventions. As a result, staff were unprepared to manage the resident's behaviors, which included physical and verbal aggression, wandering into other residents' rooms, and rejection of care. Care plans and interventions were either delayed or implemented after the resident was hospitalized following an altercation with another resident. Another resident with psychosis, vascular dementia, and major depressive disorder also demonstrated increasing aggressive behaviors and medication refusals after admission. The facility did not assess these behaviors or develop appropriate psychosocial interventions based on observed patterns. The resident's refusal to take prescribed medications, which were critical for managing dementia and behavioral symptoms, was not adequately addressed in the care plan. The lack of assessment and intervention contributed to repeated altercations between residents, resulting in injury and hospitalization. Additionally, the facility did not assess or address the psychosocial needs of two other residents following multiple altercations, nor did it have a plan for managing residents with parole status or criminal backgrounds.
Failure to Document and Report Resident-to-Resident Abuse to Police
Penalty
Summary
The facility failed to ensure that an allegation of resident-to-resident abuse was properly reported to law enforcement as required. Specifically, one resident alleged that another resident hit and pinched them in the courtyard. The facility's internal report stated that the police were notified and an investigation was initiated, with both residents assessed and found to have no injuries. However, upon review, there was no documentation or evidence to support that the police were actually contacted. The facility was unable to provide a police report or any record of the call, and the Nursing Home Administrator could not locate any documentation of the notification. The local police department also confirmed that no calls for service were received from the facility during the relevant dates.
Failure to Update and Individualize Care Plans After Resident Altercation and Inconsistent Smoking Assessments
Penalty
Summary
The facility failed to update and individualize the comprehensive person-centered care plans for two residents following a resident-to-resident altercation. Despite an incident in which one resident alleged being hit by another in the courtyard, the care plans for both individuals were not revised to include new, specific interventions to prevent further abusive situations. The care plans contained previously initiated interventions, such as using separate courtyard doors, which had not been effective in preventing the altercation. Staff interviews confirmed that while verbal education and separation of the residents were implemented, these actions were not documented or reflected in the residents' care plans. Additionally, inconsistencies were found between the residents' care plans and their smoking risk assessments. For one resident, the care plan indicated the need for supervised smoking due to unsafe behaviors, but the smoking risk assessment allowed the resident to keep their own smoking materials and did not clarify the supervision requirements. The other resident's care plan required supervision and staff-secured smoking materials, yet the risk assessment indicated the resident could smoke without supervision and keep their own materials. These contradictions were not addressed or reconciled in the care plans or assessments, and no updates were made following the most recent assessments or incidents. The facility's own policies require that care plans be updated after significant changes in a resident's condition or after incidents such as altercations. However, the care plans for both residents did not reflect the interventions discussed by staff or the outcomes of the facility's investigations. The lack of timely and individualized updates to the care plans, as well as the inconsistencies between assessments and care plan interventions, contributed to the deficiency identified by the surveyors.
Failure to Accommodate Resident's Shower Preferences Due to Cold Shower Room
Penalty
Summary
A deficiency was identified when the facility failed to reasonably accommodate the needs and preferences of a resident who expressed concerns about the shower room being too cold, resulting in the resident refusing showers. The resident, who is cognitively intact and has multiple medical diagnoses including excoriation, heart failure, and dependence on supplemental oxygen, reported not having had a shower in three months due to the cold temperature of the shower room. Despite the resident's repeated communication of this concern to staff, no interventions were offered to help the resident stay warm during showers, and the only documented hygiene provided in the last 30 days was a single bed bath. Staff interviews confirmed awareness of the resident's refusals and the stated reason of being cold, but there was a lack of documented follow-up or alternative accommodations to address the resident's comfort. The care plan and electronic health record noted the resident's preferences and history of refusals, but did not include specific interventions to mitigate the temperature issue or to reapproach the resident with solutions. Documentation of refusals did not include explanations of risks and benefits or evidence of reapproaching the resident as required by the care plan. Maintenance staff and administration acknowledged being informed of the temperature concerns and noted that the shower room temperature was measured at 73.7°F, with the baseboard heater at 87°F. While the facility was considering options to improve heating, such as additional heaters or heating lamps, no immediate accommodations were implemented to address the resident's comfort during showers. The lack of timely and reasonable accommodations led to the resident not receiving showers in accordance with their needs and preferences.
Failure to Timely Report Allegation of Staff Mistreatment
Penalty
Summary
The facility failed to report an allegation of staff mistreatment involving one resident to the Nursing Home Administrator and the State survey agency within the required timeframe. The resident, who was cognitively intact and had multiple medical conditions including diabetes, hemiplegia, peripheral vascular disease, depression, atrial fibrillation, and a left below-knee amputation, voiced concerns to two LPNs about staff being rough with him during care. Both LPNs acknowledged that the resident complained of staff roughness, particularly during changes and care related to his knee pain, but neither reported the allegation to the Director of Nursing or the Administrator as required by facility policy. One LPN documented the concern in the 24-hour report but did not escalate it further. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that neither was made aware of the resident's complaints. The facility's policy requires immediate reporting of all alleged violations to the Administrator and state agency, but this process was not followed. The failure to report the allegation of mistreatment resulted in the incident not being investigated or communicated to the appropriate authorities as mandated.
Failure to Investigate Allegations of Abuse and Resident Altercation
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, exploitation, or mistreatment were investigated or thoroughly investigated in a timely manner for two separate incidents involving three residents. In the first incident, a resident with multiple medical conditions, including diabetes, hemiplegia, and amputation, repeatedly complained to two LPNs that staff were being rough with him during care, particularly due to his knee pain. Both LPNs acknowledged hearing these complaints but did not report them to the Director of Nursing (DON) or the Nursing Home Administrator (NHA), nor did they initiate an investigation. The DON and NHA were unaware of the complaints until informed by the surveyor, and no investigation was conducted prior to the resident's discharge. In the second incident, two residents with severe cognitive impairment were involved in a resident-to-resident altercation, where one struck the other in the face, resulting in a chin abrasion and facial swelling. The facility's misconduct incident report lacked critical details, such as the names of witnesses and staff statements describing the events before, during, and after the altercation. The working schedule for the day of the incident was incomplete, making it unclear which staff were assigned to the residents involved. The care plans for the resident who initiated the altercation were not updated with new interventions following the incident, and the investigation did not include a root cause analysis or comprehensive documentation as required by facility policy. The facility's policy mandates immediate and thorough investigation of all allegations of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved parties, and providing complete documentation. In both cases, these procedures were not followed, resulting in a lack of timely and thorough investigation into the reported and observed incidents. The surveyor found that the facility did not meet its own policy standards or regulatory requirements for responding to and investigating allegations of abuse and resident-to-resident altercations.
Failure to Apply Tubigrips as Ordered for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, aphasia, vascular dementia, anxiety disorder, and paranoid schizophrenia did not receive care in accordance with physician orders and the comprehensive care plan. The resident's care plan and physician orders specified that tubigrips were to be applied in the morning and removed at bedtime to address edema. The resident was assessed as severely cognitively impaired and dependent for lower body dressing, with these interventions documented in the CNA Kardex and treatment administration record (TAR). On multiple occasions throughout the day, surveyors observed the resident without tubigrips, despite documentation in the TAR indicating they had been applied as ordered. Staff interviews confirmed awareness of the care plan requirements, and the DON acknowledged the expectation that staff follow the care plan and Kardex. The deficiency was identified due to the failure to ensure the resident received the prescribed treatment and care as ordered and documented.
Failure to Ensure Consistent Use of Hand Splint for Resident with Contracture
Penalty
Summary
A deficiency was identified when a resident with a history of hemiplegia and hemiparesis following a cerebral infarction, as well as other chronic conditions, was not provided with appropriate treatment and services to maintain or improve range of motion (ROM) in the right hand. The resident had a significant contracture in the right hand and was recommended by occupational therapy to wear a right hand splint during waking hours to prevent further decline in ROM. Despite these recommendations, the resident was repeatedly observed by the surveyor not wearing the splint, and the splint was seen on the resident's counter rather than in use. Review of the resident's care plan and medical records revealed inconsistencies and omissions. The current care plan did not include an intervention for the resident to wear the right hand splint, and previous interventions related to splint use had been marked as resolved without documented justification. Occupational therapy and medical assessments continued to recommend daily splint use, but these recommendations were not reflected in the active care plan or consistently implemented by staff. Additionally, the resident's Kardex did not document the need for a right hand splint, and there was no evidence of regular monitoring or documentation of splint application, resident refusals, or staff interventions as required by facility policy. Interviews with staff indicated a lack of consistent communication and documentation regarding the resident's use of the splint and any refusals. The resident stated willingness to wear the splint if assisted, but reported that staff had not offered to help with application on the day of observation. Staff confirmed awareness of the splint but did not consistently report refusals or ensure the splint was applied. Facility leadership acknowledged that refusals and interventions should be documented, but no such documentation was found during the survey.
Failure to Provide Ordered Ostomy Supplies and Care
Penalty
Summary
A resident with a history of bowel obstruction and an ostomy device did not receive ostomy care and supplies consistent with professional standards of practice. The resident was observed using paper towels and washcloths in place of proper ostomy supplies due to the facility running out of the required items. Multiple staff interviews confirmed that the facility did not maintain a stock supply of ostomy supplies, and there was confusion among staff regarding the ordering process and responsibility for ensuring adequate supply. The resident's care plan indicated a preference for self-care of the colostomy, but also documented behaviors such as resistance to care and use of non-standard materials, which led to skin irritation and incontinence. The resident's medical record included orders for a two-piece ostomy system, with instructions to provide two pouches per shift and change the wafer every seven days. However, staff interviews revealed that the resident was not provided with the correct supplies as ordered, and there was a lack of clarity about the type and quantity of supplies to be provided. Staff also reported that the resident's insurance only covered one pouch per day, and there was no clear process for requesting an increase in supply quantity. Documentation showed that the last delivery of ostomy supplies occurred about a month prior to the survey, and at the time of the survey, the resident had run out of supplies and was waiting for a new order to arrive. Observations by the surveyor confirmed that the resident experienced leakage of bowel contents onto their gown and expressed discomfort due to the lack of appropriate supplies. Staff responses to the situation were inconsistent, with some unaware of the resident's current supply status and others unsure of the correct procedure for addressing supply shortages. The facility's failure to provide the ordered ostomy supplies and maintain an adequate stock resulted in the resident not receiving care in accordance with professional standards.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
A deficiency was identified when a registered nurse was observed dispensing medications to a resident without following proper infection control procedures. Specifically, the nurse handled each pill with bare hands, including opening over-the-counter medications and popping pills from a blister pack directly into her bare hands before placing them into a medication cup for the resident. The facility's policy requires staff to adhere to infection control practices, such as handwashing and the use of gloves, during medication administration. During an interview, the nursing home administrator confirmed that this was not the appropriate way to handle medications.
Lack of Qualified Director in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that a qualified individual was designated as the Director of Food and Nutrition Services for all 83 residents. The personnel record for the Dietary Manager (DM) showed no education related to food services. During an interview, the DM, who had been in the position for about a year, admitted to not being aware of the requirement for certification and stated that no one had informed her of the need for certification. She acknowledged that having certification would be beneficial and mentioned that she was scheduled to take the Managerial ServSafe certification exam soon. The Administrator, during a separate interview, was unsure about the DM's certification status but confirmed that the DM was enrolled for an examination.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notices of transfer or discharge to four residents and/or their power of attorney (POA) as required by their Transfer and Discharge Guideline policy. The policy mandates that written notice be given to residents and their representatives in a manner and language they understand. However, the facility only provided verbal notifications, which is insufficient according to the policy. Resident 331, who was admitted with multiple diagnoses including Myasthenia Gravis and dementia, was sent to the hospital after a fall. Although the POA was verbally notified, there was no written transfer notice documented. Similarly, Resident 11, with severe cognitive impairment, was transferred to the hospital after an episode of unresponsiveness, but again, only verbal notification was given to the POA, with no written documentation. Resident 57, with severe cognitive impairment, and Resident 18, with intact cognition, were both transferred to the hospital multiple times. In both cases, the facility failed to provide written notices of transfer, relying instead on verbal communication with the POAs or the residents themselves. Interviews with the Admissions Director and the Director of Nursing revealed a lack of familiarity with the regulations regarding transfer forms, contributing to the deficiency.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to residents or their representatives upon transfer to a hospital, as required by their own policy. This deficiency was identified for four residents, each of whom was transferred to a hospital without receiving the necessary written documentation. The facility's policy, dated 04/25/19, mandates that residents or their representatives be given written information about the duration of the state bed-hold policy, the reserve bed payment policy, and the facility's policies regarding bed-hold periods before a transfer occurs. Resident 331, who was admitted with multiple diagnoses including Myasthenia Gravis and dementia, was transferred to the hospital after a fall, but only verbal consent was documented from the POA. Resident 11, with severe cognitive impairment due to conditions like Parkinson's disease and schizophrenia, was transferred after a medical episode, and again, only verbal notification was documented. Resident 57, with severe cognitive impairment and conditions such as heart failure, was transferred twice, with only verbal notifications documented for both instances. Resident 18, who had intact cognition, was transferred multiple times, and although she declined a bed hold on one occasion, she reported not receiving written notice of the policy. Interviews with the POAs and residents revealed that they did not receive any paper documentation regarding the bed hold policy, leading to potential confusion or distress. The Admissions Director confirmed that verbal notices were given, and the DON admitted unfamiliarity with the regulations concerning bed hold forms. This lack of adherence to policy could affect 83 residents, potentially causing confusion or distress regarding their return to the facility after hospitalization.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food prepared and served to residents was at a palatable temperature, affecting five out of six residents reviewed for palatability. Residents reported that the food was consistently cold, lacked variety, and was not flavorful. Specific residents, including those with varying levels of cognitive impairment, expressed dissatisfaction with the temperature and quality of the meals. Observations during meal preparation confirmed that food temperatures dropped significantly from the steam line to the point of service, with rice, chicken patty, and broccoli served at temperatures well below the initial cooking temperatures. During an observation, a test tray was prepared and served, revealing that the food temperatures had decreased significantly by the time it reached the residents. An LPN who tested the tray found the chicken patty difficult to chew and the rice and broccoli cold and bland. The Dietary Manager was surprised by the findings, despite acknowledging past concerns about food temperatures. The Director of Nursing expected the food to be enjoyable and chewable, but the facility's policy on food service preparation, which was last revised in July 2014, was not effectively ensuring compliance with safe food handling practices.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, was assessed and evaluated for the self-administration of medications. R30, who was admitted with a diagnosis of acute respiratory failure, was found to have a BIMS score indicating cognitive intactness. During observations, it was noted that R30 had a bottle of Fluticasone and saline nasal spray on the bedside table, which the resident confirmed were their medications. However, there were no physician orders for the administration of Fluticasone nasal spray, and the resident's care plan lacked documentation regarding self-administration of medication. Further observations and interviews revealed that R30 also had generic Sudafed pills in the room, and the resident refused to let staff remove the medications, claiming ownership. The LPN and DON confirmed that an assessment for self-administration had not been conducted for R30, despite the presence of medications in the room. The facility's policy requires an interdisciplinary team to determine the safety of self-administration, and a licensed nurse must complete an evaluation to assess the resident's ability to self-administer medication. This process was not followed for R30, leading to the deficiency.
Medication Administration and Reconciliation Failures
Penalty
Summary
The facility failed to properly reconcile, transcribe, and administer medications for three residents, leading to potential adverse health outcomes. For one resident, new medication orders following a hospital discharge were not entered into the electronic medical record (EMR) or administered until four days after the resident's return, despite the Director of Nursing's expectation that new orders be entered within a few hours. This delay in administering antibiotics and steroids could have impacted the resident's recovery from acute on chronic respiratory failure. Another resident experienced a lapse in medication management when their antidepressant, sertraline, was not included in the medication administration record (MAR) upon return from the hospital. The facility's staff did not notify the nurse practitioner of the omission, which was significant given the high dose of sertraline the resident had been receiving. The nurse practitioner was unaware of the discontinuation until a follow-up visit, which hindered the planned tapering of the medication. A third resident was administered an incorrect dose of aspirin and did not receive their scheduled insulin during a morning medication pass. The registered nurse involved initially claimed to have administered all medications but later confirmed the errors upon review. These incidents highlight failures in medication administration and reconciliation processes, as well as lapses in communication among the facility's staff.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care treatments as ordered for a resident who was admitted with a primary diagnosis of aftercare following a surgical amputation. The resident, who had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, was supposed to receive daily wound care for his left leg below-knee amputation site. However, the Treatment Administration Record (TAR) indicated that the resident did not receive wound care on two consecutive days, with the staff member marking the treatment as refused without proper documentation or a corresponding progress note. Interviews revealed that the Wound Care Registered Nurse (WCRN) provided wound care during weekdays, while the nursing staff was responsible for weekends. The WCRN noted that the resident had a habit of refusing care if not provided by preferred nurses, but emphasized the importance of documenting refusals and reapproaching the resident. The Director of Nursing (DON) confirmed that there was a lack of appropriate documentation and communication regarding the refusals, which contributed to the failure in providing care as per the physician's orders.
Failure to Follow Physician Orders for Oxygen and CPAP
Penalty
Summary
The facility failed to adhere to physician orders for oxygen administration and CPAP treatment for two residents. For one resident, the oxygen concentrator was consistently set at 5 liters per minute (LPM), contrary to the physician's order of 3 LPM. This discrepancy was observed over several days, and both a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the incorrect setting. The resident's care plan did not document any non-compliance by the resident to maintain the prescribed oxygen level. For another resident, the facility administered CPAP treatment without a current physician's order. Although the resident's family member confirmed the nightly use of the CPAP, and the treatment was documented in the Treatment Administration Record, there was no physician's order for the CPAP upon the resident's readmission to the facility. The LPN and DON confirmed the absence of a current order, noting that the treatment continued based on a previous order before the resident's hospital stay.
Failure in Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure ongoing pre- and post-dialysis communication for a resident receiving dialysis three times a week. The resident, identified as R59, was readmitted with a diagnosis of end-stage renal disease and required dialysis treatment. Despite the resident's care plan and physician orders indicating the need for dialysis three times weekly, there were no completed pre- and post-dialysis communication forms in the resident's electronic medical record. Interviews with facility staff, including the Assistant Director of Nursing and a Licensed Practical Nurse, revealed that there were no established communication forms or processes in place to share vital information such as weights and vitals with the dialysis center. The Director of Nursing acknowledged that communication with the dialysis center was conducted on an as-needed basis, and there were no longer any binders for dialysis residents, although there used to be. The facility's policy on dialysis communication, which was last revised in 2007, required written communication forms to include daily weights and any changes in condition or mood. The lack of adherence to this policy and the absence of a structured communication process between the facility and the dialysis center contributed to the deficiency identified by the surveyors.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that residents received medications as ordered by their physicians, affecting four residents. For one resident with anemia in chronic kidney disease, a retacrit injection was not administered on the scheduled date because the pharmacy did not receive the necessary lab results in time. The Unit Manager failed to confirm the receipt of the labs by the pharmacy, resulting in a delay in medication administration. Another resident with rheumatoid arthritis did not receive their prescribed adalimumab injections on multiple occasions. The LPN, who was an agency nurse, was unaware of the process to ensure medication refills, leading to missed doses. The Director of Nursing acknowledged a lack of communication between the facility's electronic medical records and the pharmacy, which contributed to the issue. A third resident did not receive their glucosamine-chondroitin medication due to a lack of clarity in the order and the absence of the medication in the facility. The RN administering the medication was unable to find the correct formulation and needed to clarify the order with the nurse practitioner. Lastly, a resident with a new order for carbidopa-levodopa experienced a delay in receiving the medication due to insurance issues and a lack of communication between the facility and the pharmacy. The medication was on back order, and the facility had not documented the situation adequately.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 12.9 percent error rate during the observation of medication administration. This deficiency affected two residents. One resident, admitted with chronic pain, did not receive her prescribed glucosamine-chondroitin due to the absence of a specified dose in the order, which led the nurse to withhold the medication. The resident confirmed she had not received the medication since admission, understanding it was an over-the-counter drug not yet available at the facility. Another resident, with diagnoses including heart failure and restless legs syndrome, did not receive her prescribed carbidopa-levodopa due to insurance issues and a delay in delivery. The medication was on hold, and although the pharmacy had sent a supply, it was not available for administration. The resident was aware of the situation and expressed concern over not receiving an oral antibiotic after a hospital visit. The facility had the immediate release form of the medication in their contingency supply, which was used as a temporary substitution.
Medication Security and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the security of medication carts and the proper administration of medications, as observed on Unit 3 Hall. A medication cart was found unlocked and unattended in the hallway, with the computer screen slightly down but not locked. This occurred while a resident in a wheelchair used the cart to pull himself past, and other staff and visitors walked by. An LPN acknowledged the cart was unlocked but did not provide further explanation. The Director of Nursing (DON) confirmed that it is a basic expectation for nurses to lock medication carts when not in view, as per the facility's policy. Additionally, the facility did not secure medications during administration for a resident, identified as R37. The resident's medical record indicated a history of acute respiratory failure and muscle weakness, with a cognitive status deemed intact. An observation revealed that medications were left on the bedside table while the resident was asleep. The LPN responsible confirmed leaving the pills at the bedside, assuming the resident had taken them. The DON acknowledged that medications should not be left unsecured and should be administered when the resident is available, as outlined in the facility's medication administration policy.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to adhere to infection prevention standards during a medication pass, specifically in the use and cleaning of glucometers. Observations revealed that a registered nurse (RN) did not disinfect the glucometer between uses on two residents, both of whom had diabetes and required regular blood glucose monitoring. The RN used the same glucometer on both residents without cleaning it, and failed to perform hand hygiene before and after handling the glucometer and administering medications. Additionally, personal food items were found on the medication cart, which is against facility policy. Resident 282, who had a severely impaired cognitive status, and Resident 135, who had intact cognition, were both subjected to blood glucose checks with the same uncleaned glucometer. The RN did not follow the facility's policy of using Clorox Bleach Germicidal Wipes to clean the glucometer between residents, nor did she perform hand hygiene as required by the facility's hand hygiene policy. The Director of Nursing confirmed that the facility's policy was not followed, and that personal food items should not be on the medication cart.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in an injury. Resident 25, who is severely cognitively impaired with a BIMS score of six, was involved in an incident with Resident 66, who also has severe cognitive impairment with a BIMS score of three. The incident occurred when Resident 25 accidentally rolled over Resident 66's toes with a wheelchair, prompting Resident 66 to aggressively grab and twist Resident 25's arm, causing bruising. This event was witnessed by staff, who intervened to separate the residents. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the lack of an updated care plan for Resident 66 following the aggressive behavior. Although the incident was reported to the Administrator, state agency, and local police, the care plan for Resident 66 did not reflect any new interventions to address the aggressive behavior demonstrated during the incident. The facility's failure to update the care plan for Resident 66 represents a deficiency in ensuring resident safety and preventing abuse.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the state agency involving two residents. One resident, with moderately impaired cognition, reported being slapped by another resident with intact cognition while in the smoking area. The incident was not witnessed by others, and the facility did not document the allegation in the electronic medical records or the incident report. The facility's investigation was kept in a soft file, and the decision not to report was based on an algorithm that indicated no harm was done to the resident. The Director of Nursing (DON) and the Administrator were aware of the allegation, but the facility did not report it to the state department. The DON stated that the facility's policy required reporting within two hours if the allegation involved abuse or resulted in serious bodily injury. However, the facility's algorithm did not indicate the need to report, as it concluded there was no harm. The resident's story was consistent, but the facility's decision not to report was based on the resident's statement of feeling safe and the algorithm's directive.
Failure to Update Care Plans for Aggressive Behavior, Alcohol Use, and Catheter Change
Penalty
Summary
The facility failed to update the care plan for a resident, R66, who exhibited aggressive behavior following an incident where R66 twisted another resident's arm, causing injury. Despite the incident being witnessed by staff and immediate intervention to separate the residents, the care plan for R66 was not updated to reflect this aggressive behavior. Both the Regional Nurse Consultant and the Director of Nursing confirmed that the care plan should have been updated according to the facility's policy, which requires changes in a resident's condition to be reported for assessment and care plan review. Another deficiency was identified with resident R77, who had a history of alcohol dependence and exhibited disruptive behaviors upon returning to the facility intoxicated on multiple occasions. Despite several documented incidents of intoxication and disruptive behavior, including verbal abuse and refusal of medication, R77's care plan did not include any interventions for alcohol use or related behaviors. Interviews with nursing staff and the MDS Coordinator revealed a lack of communication and oversight in updating the care plan to address these issues, despite expectations that such behaviors should be care planned. Additionally, the facility failed to update the care plan for resident R69, who underwent a procedure to replace a Foley catheter with a suprapubic urinary catheter. Although there were orders for daily care and monitoring of the suprapubic catheter site, the care plan still referenced the previous Foley catheter and did not include the new catheter care requirements. The Director of Nursing acknowledged that the care plan should have been updated to reflect the change in catheter type and care needs.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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