Madison Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Wisconsin.
- Location
- 110 Belmont Rd, Madison, Wisconsin 53714
- CMS Provider Number
- 525074
- Inspections on file
- 47
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Madison Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with left-sided hemiplegia, vascular dementia, and severe cognitive impairment was turned onto her paralyzed left side on a low air loss mattress for perineal care, away from the CNA and without a left-side enabler bar for her functioning right arm. While the CNA turned away to reach for additional wipes and did not maintain secure contact, the resident slid off the left side of the bed to the floor. Initial nursing assessment documented no apparent pain, but the following day a CNA heard a cracking sound in the resident’s right leg during repositioning, after which the resident reported significant right hip pain. An x-ray was initially negative, but a subsequent CT scan in the ER showed a mildly displaced, slightly comminuted fracture of the greater trochanter of the right femur, demonstrating that the facility failed to provide adequate supervision and safe positioning to prevent an accident.
A resident with cerebral palsy, epilepsy, DM, anxiety, documented weight loss, and risk for malnutrition had a care plan and meal ticket specifying adaptive equipment, including a lipped plate and heavy weight built-up silverware. During a breakfast observation, the resident was served regular silverware instead of the ordered built-up utensils, reported that staff did not listen when she requested them, and was seen having difficulty eating with a regular spoon. A CNA and the DON both confirmed that the resident was supposed to receive built-up utensils per the care plan and meal card, but these were not provided.
Facility staff failed to follow warewashing standards requiring dishware to be air dried and properly stored after cleaning and sanitizing. A dietary aide removed multiple glass plates, metal plate warmers, and lids from the dish machine while still visibly wet, stacked them on a cart, and intended to place them into a plate warmer. The items were then moved to a drying rack but remained stacked while wet, and later inspection by the kitchen manager and surveyor revealed condensation still present between plates, confirming they could not air dry properly when stacked. Management acknowledged that wet stacking should not occur and that the aide had not been correctly trained.
A resident with intact cognition and a history of diabetes, schizophrenia, and major depressive disorder was evaluated by an audiologist, found to have mild to severe bilateral sensorineural hearing loss, and was recommended binaural hearing aids. The facility’s policy requires ensuring access to hearing services and adaptive equipment, and the process involves the SW receiving audiology summaries, routing needed orders to nursing, and completing consent and financial steps. Despite the audiology recommendation and an order for hearing aids, the resident reported never receiving any hearing aids or amplification device, and record and staff interviews confirmed that the order was not carried out and no hearing-related care plan was in place.
The facility failed to properly explain binding arbitration agreements to two cognitively intact residents before obtaining their signatures. Policy required that arbitration be explained in a manner residents understand and clarified that disputes would be resolved by an arbitrator rather than through the judicial system. One resident did not recall any explanation and, when shown the signed agreement, stated they would not have agreed to it. Another resident believed signing would simply allow them to dispute issues and did not understand that it waived access to the courts; after the surveyor clarified this, the resident stated it had not been explained that way and they would not have signed. The BOM described arbitration to residents as a step before going to the legal system, which conflicted with the agreement’s language, while the NHA acknowledged the form barred use of the legal system and that residents should not sign documents they do not understand.
A resident with chronic health conditions and cognitive intactness requested that staff wear masks when entering his room, as indicated by signage. Multiple staff members entered without masks and did not ask for permission, and the resident confirmed this was upsetting. The resident's preference was not included in his care plan, and staff did not consistently respect his wishes, resulting in a failure to honor his right to self-determination and dignity.
A resident with severe cognitive impairment was found to have a commode in their room with a brown substance, identified by an LPN as likely stool, which remained uncleaned for over an hour. Staff interviews confirmed the commode should have been cleaned after use, in accordance with facility policy requiring sanitary resident care equipment.
The facility did not submit the results of an internal investigation into an alleged misappropriation of a resident's property to the State Agency within the required 5 working days, instead submitting them after 6 working days. The delay was due to waiting for a response from the resident's family, and the Nursing Home Administrator acknowledged the late reporting during a surveyor interview.
The facility did not attempt alternatives or conduct required assessments before installing bed rails or enabler bars, especially with air mattresses, for multiple residents. Staff interviews and record reviews revealed a lack of documentation for risk assessment, informed consent, and discussion of risks and benefits. Residents with cognitive impairment, mobility issues, and fall histories were affected, and gaps between mattresses and rails were observed, increasing entrapment risk.
Three residents at risk for pressure injuries did not receive care consistent with professional standards, resulting in the development and worsening of pressure ulcers. One resident developed an unstageable sacral wound that progressed to a stage IV infection due to delayed interventions, inconsistent repositioning, and lack of timely air mattress provision. Another resident developed an unstageable heel wound after staff failed to implement offloading and did not promptly assess or notify the provider. Staff were also observed performing wound care without proper PPE or hand hygiene, and documentation of care was inconsistent.
A facility failed to implement and maintain an effective infection control program, resulting in the spread of multi-drug resistant organisms among several residents. Staff did not follow proper hand hygiene or PPE protocols during resident care, and soiled linens were handled inappropriately. Infection control policies were not reviewed annually, and staff were not consistently educated on infection prevention practices, contributing to the transmission of infections.
Three residents did not receive care according to physician orders and professional standards, including failures to monitor weight and notify providers of significant changes for a resident with CHF and malnutrition, inadequate monitoring and delayed response to bleeding in a resident on anticoagulants, and not following wound care orders for another resident. These failures resulted in hospitalizations and actual harm.
Surveyors found that nutritional supplements were stored without required thaw dates and that a low-temperature dishwasher was operated with insufficient chlorine levels, with staff failing to report the issue as required.
Garbage and refuse were not properly disposed of, as observed by a surveyor and the Dietary Manager. Used gloves, bags of garbage, and numerous cigarette butts were found scattered around the main dumpster area, with the Dietary Manager confirming the garbage had been present for over a week. This issue had the potential to affect all 66 residents.
The facility's assessment did not accurately reflect the resident population or necessary resources, omitting key details such as language needs for non-English speakers, staff competencies for dialysis care, and infection control practices. Staff were unable to communicate with residents in their preferred languages, failed to demonstrate appropriate responses to dialysis emergencies, and did not implement timely interventions for pressure injuries. Infection prevention lapses and inadequate assessment and use of assistive equipment were also observed, indicating the assessment did not address all required areas.
Physicians did not consistently review and sign monthly orders for several residents, with documentation missing for multiple consecutive months. The DON and Interim Administrator confirmed that monthly signatures were expected but not completed, and the EHR system did not prompt physicians to sign as required.
Annual performance evaluations were not completed for four out of five CNAs reviewed, despite facility policy and federal requirements. Both the DON and Interim Administrator confirmed that yearly evaluations are expected and should be up to date, but records showed these evaluations were missing.
Surveyors found that a resident's room and multiple shower rooms were not maintained in a clean or homelike condition, with dried substances on furniture and walls, and visible grime and residue in shower areas. Two residents voiced concerns about shower cleanliness, and staff confirmed that cleaning practices were not consistently followed, resulting in an environment that did not meet required standards.
Two residents were left to self-administer medications without required clinical assessments. One resident with severe cognitive impairment was left alone with a shake containing multiple medications, and another cognitively intact resident had a cup of medications left at her bedside. In both cases, staff confirmed that no self-administration assessments had been completed, contrary to facility policy.
A resident who speaks only Spanish and has a history of cerebral infarction and major depressive disorder was not provided with activities tailored to her language or cultural background. Staff were unaware of her preferences, did not use translation tools during activities, and did not offer Spanish-language entertainment or culturally relevant engagement. The resident was often observed to be restless, bored, and isolated, with family reporting she felt misunderstood and alone.
A resident requiring dialysis did not receive consistent monitoring or assessment before and after treatments, as required by physician orders and facility policy. The care plan lacked dialysis-specific interventions, and documentation of vital signs and weights was incomplete. Staff interviews revealed inadequate knowledge of emergency procedures for bleeding from a dialysis fistula, with CNAs indicating they would leave the resident to get a nurse rather than apply immediate pressure.
Three residents were not seen by a physician or physician extender at the required intervals, with missed visits spanning several months and improper alternation between physician and extender visits. Facility policy requires timely provider visits and proper documentation, but these standards were not met according to record review and staff interviews.
Nursing staff failed to use available interpreter services and did not demonstrate cultural competency when caring for three non-English speaking residents with communication needs. Instead, staff relied on gestures, body language, and ad hoc translation tools, leading to ineffective communication and resident frustration. Despite care plans and facility policy requiring the use of qualified interpreters, staff did not consistently follow these procedures, resulting in a lack of meaningful communication for residents who spoke Spanish, Hmong, and Russian/Ukrainian.
The facility did not follow its antibiotic stewardship program, resulting in inappropriate antibiotic use for three residents. One resident was treated for a UTI without meeting diagnostic criteria, and two others received prophylactic antibiotics without proper justification or documentation. Required monitoring, provider communication, and education were not completed or documented by the Infection Preventionist or DON.
A resident with a suprapubic catheter developed a severe candidal rash that was not documented by facility staff, nor was the provider notified of the change in condition. The issue was only identified after the resident was sent to the ED, where the diagnosis and treatment were made. Facility policy requires prompt notification of the provider for such changes, but this was not followed.
A resident and her family reported multiple grievances, including issues with oxygen setup, call light response, and communication with staff. The facility did not complete or document required interviews, staff education, or follow-up with the resident or family, and failed to provide written decisions or confirm satisfaction with the outcomes, as required by its grievance policy.
Two residents were affected by inaccurate MDS assessments: one was incorrectly documented as receiving hospice services despite never enrolling, and another was reported as having a pressure injury when only a venous stasis ulcer was present. Both errors were confirmed by interviews and record reviews, with staff acknowledging the MDS should accurately reflect each resident's actual status.
A resident with severe cognitive impairment and a history of refusing care did not have documentation showing that scheduled showers were offered, received, or refused on multiple occasions. Despite the care plan and expectations for staff to document refusals after multiple attempts, records lacked evidence of these actions, and the concern was also raised by the resident's Power of Attorney for Health Care.
A resident with severe cognitive impairment and a history of falls did not have required fall prevention interventions in place, including a bed in the lowest position, fall mats, and an accessible call light. Staff reported the bed was broken and had not notified maintenance, and fall mats were missing from the room. The care plan interventions were not followed as required by facility policy.
A resident with an indwelling urinary catheter was found to have their catheter bag uncovered and resting on the floor, contrary to infection control guidelines and the facility's care plan. Both a CNA and the DON confirmed this was not acceptable practice, and the resident's care plan included specific interventions to prevent UTIs that were not followed.
Two residents experienced unwitnessed falls, and the facility failed to document post-fall clinical findings or evaluate the effectiveness of fall interventions. Despite staff indicating that monitoring should occur for 72 hours, the facility could not provide documentation of such monitoring for these residents.
The facility failed to maintain a clean and sanitary environment for food storage and preparation, affecting all 64 residents. Observations included dust in the dry storage area, undated or expired food in coolers, nicked spatulas, and an unclean microwave. Staff's personal water bottles were stored with residents' food, and residents accessed the ice chest unsupervised, risking contamination. A resident confirmed the practice, and staff acknowledged the potential for contamination.
The facility did not ensure a clean and safe environment for residents, as observed by surveyors. Bags of soiled linen and trash were left in a hallway, and staff failed to promptly clean a soda spill in a resident's room. Additionally, a bag of wet linen was left on a resident's floor, indicating lapses in maintaining cleanliness and safety.
The facility failed to notify the State Long-Term Care Ombudsman of transfers or discharges for seven residents, as required by policy. The social worker could not provide documentation of these notifications, acknowledging they had not been done.
The facility failed to provide required written bed-hold notices to residents or their representatives during hospital transfers. Six residents were transferred multiple times without receiving the necessary documentation, despite the facility's policy requiring such notices. The social worker confirmed the oversight, admitting that the notices were not completed as required.
The facility did not complete PASARR Level II evaluations for residents with serious mental disorders who stayed longer than 30 days, despite policy requirements. This affected residents with conditions like schizophrenia and major depressive disorder, who were on psychotropic medications. Interviews confirmed that only PASARR Level I screens were completed.
The facility failed to provide scheduled showers to four residents, leading to a deficiency in ADL care. One resident with intact cognition reported missing showers due to staff not offering them or not having time. Another resident with severely impaired cognition also reported not receiving scheduled showers. Documentation showed inconsistencies and missed showers for these residents, with staff failing to document refusals or reapproach residents. A CNA admitted to not documenting refusals and being unaware of a resident's shower schedule.
The facility failed to provide adequate supervision and safety measures for residents at risk of elopement and smoking hazards. A resident at risk for elopement did not have a code alert bracelet, and staff failed to replace it, allowing the resident to leave the facility without triggering an alarm. Another resident returned from the hospital without a code alert bracelet, and staff did not promptly replace it. Additionally, a medication cart was left unlocked and unattended, and a resident's care plan contained conflicting instructions regarding smoking supervision, leading to staff confusion.
The facility failed to provide appropriate trauma-informed care for residents with a history of trauma, mental disorders, or psychosocial adjustment difficulties. Care plans for four residents lacked personalized interventions, triggers, and goals related to their trauma histories. Staff were unaware of specific triggers and interventions, and recommendations from mental health services were not incorporated into care plans.
A LTC facility experienced multiple infection control breaches, including improper use of PPE during catheter care, inadequate hand hygiene during wound care, and failure to use enhanced barrier precautions. Staff were observed not following protocols, such as placing contaminated items on the floor and touching surfaces with contaminated gloves.
A resident's right to privacy and dignity was violated when a non-licensed staff member was present during personal care without explicit permission. The resident, who requires assistance due to medical conditions, reported the unauthorized presence, which was confirmed by the scheduler and deemed unacceptable by the DON.
The facility failed to follow its grievance process for two residents, leading to a deficiency. A resident with moderate cognitive impairment reported rough handling by staff, but no grievance was filed. Another resident reported missing clothes, but the grievance process was not followed when all items were not recovered. The facility's actions did not align with its policy, indicating a systemic issue in addressing resident grievances.
A resident with moderate cognitive impairment reported being handled roughly by staff, specifically mentioning "the black ones." The facility failed to report the abuse allegation to the State Agency within the required timeframe and inadequately addressed the resident's concerns. The Nursing Home Administrator initially dismissed the concern and sent a Unit Manager fitting the description of the staff involved, further upsetting the resident.
A facility failed to thoroughly investigate and protect a resident, R19, after an abuse allegation. R19 reported rough handling by staff, specifically mentioning 'the black ones.' The NHA misjudged the situation as a customer service issue and sent LPN E, who fit the description of the alleged rough staff, to speak with R19. Despite the ongoing investigation, LPN E returned to work, compromising resident safety. The investigation was incomplete and poorly documented, highlighting deficiencies in handling the abuse allegation.
A facility failed to ensure the accuracy of MDS assessments, as a resident's assessment incorrectly indicated the presence of a Foley catheter. The error was identified during a surveyor's interview with the MDS coordinator, who confirmed the mistake after reviewing the resident's chart. Facility policy mandates accurate assessments to identify care needs, and interviews with the DON and NHA confirmed the expectation for staff to complete MDS assessments accurately.
The facility failed to develop accurate, person-centered care plans for two residents. One resident's care plan lacked discharge planning, while another's contained incorrect information about medical dependencies. Staff were uncertain about care plan review processes and responsibilities, leading to these deficiencies.
Two residents were not adequately involved in their care planning process, as required by facility policy. One resident, who is cognitively intact, reported limited participation in care planning meetings, with records showing only one meeting lacking interdisciplinary input. Another resident's records indicated a care plan meeting over a year ago, with no subsequent meetings documented. Staff interviews confirmed that care conferences should occur quarterly and involve an interdisciplinary team, but these requirements were not met for the residents in question.
The facility failed to follow physician orders for two residents. One resident did not receive a required sleep assessment, and another did not have ketoconazole shampoo properly applied and rinsed as prescribed. Staff interviews confirmed these deficiencies.
A resident with respiratory and cardiac issues experienced multiple hospitalizations due to the facility's failure to conduct proper assessments and document vital signs during changes in condition. Despite the facility's policy requiring thorough evaluations, necessary respiratory and cardiac assessments were not completed prior to hospital transfers.
The facility did not ensure daily diabetic foot checks for three residents with type 2 diabetes, as required by professional standards. The facility's policy mandates daily checks, but the Treatment Administration Records did not reflect this practice. Interviews with staff revealed that foot checks are only performed when ordered by a physician, leading to a lapse in care for these residents.
Failure to Provide Adequate Supervision and Safe Positioning During Perineal Care Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and safe positioning during incontinence care, resulting in a resident falling from bed and sustaining a right hip fracture. The resident had significant medical conditions including cerebrovascular disease, left-sided hemiplegia/hemiparesis following a stroke, vascular dementia with severe cognitive impairment (BIMS 7/15), muscle weakness, and a left-hand contracture. Her care plan documented an ADL self-care performance deficit related to hemiplegia, impaired balance, stroke, and confusion, and specified that she required one staff assist for bed mobility and two staff with a mechanical lift for transfers. The care plan also allowed a right upper side rail as an enabler, which the resident used with her right arm to assist with bed mobility. On the date of the incident, a CNA was providing perineal care after the resident had a very large bowel movement. The CNA positioned the resident on her left side, which was the paralyzed side, and facing the window, with the CNA standing behind her. At that time, the bed had only a right-side enabler bar; there was no left-side enabler bar for the resident to grasp with her functioning right hand when turned toward the left. The resident was not positioned toward the CNA for added stability and did not have anything to hold onto with her right hand while lying on her left side. The CNA reported that she had one hand on the resident and used the other to pull wipes from the package, then turned to reach for more wipes. During this brief period, the resident slid or rolled off the left side of the bed onto the floor. The CNA did not witness the actual fall, as she was turned away at the moment it occurred. The administrator later identified that the resident had been on a low air loss mattress and that the resident was rolled to her weakened side without something to hold onto, while the CNA reached behind her instead of maintaining secure contact. Following the fall, the RN responding to the incident found the resident on the floor on her back with a pillow under her head, documented vital signs, and initially recorded a pain score of 0 with the resident at baseline. A fall report described the event as a witnessed fall without head injury while the resident was receiving care for a large bowel movement. The RN documented a change in condition related to the fall but did not specifically document range of motion, although she later stated she had assessed ROM and found it at baseline. The next day, another CNA reported hearing a loud cracking sound from the resident’s right leg while repositioning her on her left side, after which the resident complained of significant right hip pain. An LPN notified the provider, and an x-ray was obtained that initially showed no acute fracture. Subsequently, the resident was sent to the emergency department, where a CT scan revealed a mildly displaced, slightly comminuted fracture of the greater trochanter of the right femur. Interviews with long-term caregiving staff confirmed that it was not considered safe to walk away or turn away from this resident during perineal care, that she was typically rolled onto her left side facing the window, and that she relied on having something to grab with her right arm when turned to that side. The administrator identified the root cause as the resident being rolled to her weakened side without a grab bar on that side and the CNA turning away and removing her hand from the resident, leading to the fall from the bed.
Failure to Provide Ordered Adaptive Eating Utensils
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed adaptive eating equipment to a resident who required it. The resident, who had cerebral palsy and epilepsy and was at risk for malnutrition with documented weight loss over 180 days, had a comprehensive care plan initiated on 3/18/26 addressing nutritional problems related to multiple medical diagnoses, including epilepsy, DM, and anxiety. The care plan included an intervention, added on 4/6/26, for adaptive equipment consisting of a lipped plate and heavy weight built-up silverware. The resident’s breakfast meal ticket for 4/7/26 also specified "Built up utensils," indicating that these adaptive utensils were to be provided with meals. On 4/7/26 at 8:30 AM, the surveyor observed the resident eating breakfast with regular silverware instead of the ordered built-up utensils. The meal tray contained regular silverware despite the meal ticket indicating built-up utensils. The resident reported that she was supposed to receive built-up utensils and that when she asked staff for them, they did not listen to her. The surveyor observed the resident eating Fruit Loops with a regular spoon and having difficulty holding and using it. Later, a CNA confirmed that the resident should have built-up utensils per her care plan, and the DON also confirmed that the resident was to have built-up utensils during meals and that staff were expected to provide them according to the meal card. These observations and interviews show that the facility did not implement the care-planned intervention for adaptive eating equipment for this resident.
Improper Wet Stacking and Inadequate Drying of Dishware After Warewashing
Penalty
Summary
The deficiency involves failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, specifically related to improper drying and storage of dishware. Facility policy on warewashing requires all dishware, serviceware, and utensils to be cleaned, sanitized after each use, air dried, and properly stored, and states that dining services staff must be knowledgeable in proper dish machine processing and handling of sanitized dishware. During observation of dishwashing, a dietary aide removed multiple glass plates, metal plate warmers, and bottom lids from the dishwashing rack while they were still visibly wet and stacked them face up on a cart in separate stacks. Additional wet items were then placed on top of these stacks while still visibly wet. The dietary aide stated he planned to place these wet-stacked items into the plate warmer. The dietary manager acknowledged that the items should be dry before being placed into the warmer and confirmed that wet stacking was occurring. The aide then moved the items to a drying rack but left them stacked together while still wet. Later, when the kitchen manager separated a section of the previously wet-stacked plates, both the surveyor and the kitchen manager observed visible condensation remaining on the plates, and the kitchen manager confirmed that dishes are not able to air dry properly when stacked. The kitchen manager reported that the dietary aide was newer and had not been trained correctly, and also stated that wet stacking should not occur.
Failure to Implement Audiology Recommendation for Hearing Aids
Penalty
Summary
The deficiency involves the facility’s failure to follow through on an audiologist’s recommendation and physician order for hearing aids/amplification for one resident. The facility’s policy "Hearing and Vision Services" (revised 3/2025) states that all residents should have access to hearing services and receive adaptive equipment as indicated. Resident 60, admitted with diagnoses including Type II diabetes mellitus, schizophrenia, and major depressive disorder, had an MDS dated 8/26/2025 showing a BIMS score of 14, indicating intact cognition, and did not have a care plan related to hearing loss. During an interview, the resident reported that an audiologist had tested their hearing, said hearing aids were needed, but the devices were never provided. Record review showed the resident had an audiology appointment on 9/10/2025 with Health Direct Audiology, which documented mild to severe bilateral sensorineural hearing loss and recommended binaural hearing aids of a specific make and model, noting the resident was eager for amplification. Staff interviews revealed that audiology summaries and recommendations are emailed to the social worker (SW), NHA, and DON, with SW responsible for pulling needed items, giving orders to nursing, and following up with the resident, including consent and financial paperwork. The NHA acknowledged that the audiology recommendation for specific hearing aids existed and stated she would need to find out what happened to the order. The resident later reiterated that no amplification device had been brought despite being told something would be provided. The NHA confirmed the expected process for handling Health Direct recommendations and agreed it should be followed for all such orders, but in this case the order for hearing aids was not fulfilled and the resident did not receive the recommended devices.
Failure to Adequately Explain Binding Arbitration Agreements to Cognitively Intact Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that binding arbitration agreements were explained to residents in a form and manner they understood, and to obtain acknowledgment that they understood the agreements before signing. Facility policy dated 12/12/24 states that the facility asks all residents to enter into binding arbitration, that it is not a condition of admission or continued care, and that arbitration is a private process in which an independent arbitrator settles disputes. The policy further requires that the agreement be explained to the resident and/or representative in a way they understand. For one resident (R2), who had a BIMS score of 15 indicating intact cognition, the arbitration agreement signed and dated 1/22/26 stated that any legal dispute related to the admission agreement or services would be resolved exclusively by binding arbitration and not by a lawsuit or judicial process. During interview, R2 did not recall any conversation with the facility about binding arbitration, and upon review of the signed agreement with the surveyor, stated they would not want that. A second cognitively intact resident (R72), also with a BIMS score of 15, signed an arbitration agreement dated 2/5/26 containing the same language that disputes would be resolved exclusively by binding arbitration and not through the judicial system. In interview, R72 recalled being told there was a form to sign to allow them to dispute something and believed signing would allow them to dispute issues, but did not understand that disputes would be resolved by an arbitrator instead of the judicial system. After the surveyor explained that disputes would be handled by an appointed third party and not the courts, R72 stated it had not been explained that way and that they would not have signed if it had been. The Business Office Manager reported that they explain arbitration as a process where, in case of a dispute, the facility, resident/POA, and lawyers sit down to see if they can reach agreement before it goes to the legal system, and that if no agreement is reached it would go to court, which conflicts with the agreement’s language. The NHA acknowledged that the form states residents cannot use the legal system, that residents should not sign something they do not understand, and that staff should clearly understand and accurately explain the document to residents.
Failure to Honor Resident's Mask Preference and Right to Self-Determination
Penalty
Summary
Staff failed to honor a resident's expressed preference for staff to wear masks when entering his room. Despite clear signage on the resident's door and a dry erase board indicating this preference, surveyors observed multiple staff members, including certified nursing assistants, entering the resident's room without wearing masks and without asking the resident if it was acceptable to do so. Interviews with staff revealed that they did not consistently follow the resident's request, with one CNA stating that staff typically entered without masks and believed it did not bother the resident. However, when interviewed, the resident confirmed that it was his preference for staff to wear masks and that it did upset him when they did not comply. The resident involved had diagnoses including pneumonitis due to inhalation of food and vomit, and chronic kidney disease stage 3, and was assessed as cognitively intact. The facility's own Resident Rights admission document affirms the right to a dignified existence, self-determination, and reasonable accommodation of resident needs and preferences. Despite this, the resident's preference regarding mask use was not incorporated into his care plan, and staff did not consistently respect or accommodate his wishes, resulting in a failure to uphold his rights as outlined by facility policy.
Unclean Commode Found in Resident Room
Penalty
Summary
Surveyors observed that a commode in the room of a resident with severe cognitive impairment had a brown substance on the seat and arm, which was identified by an LPN as likely being stool. The commode remained uncleaned for at least one hour after the initial observation, despite the resident's need for assistance with toileting and the facility's policy requiring resident care equipment to be kept clean and sanitary to prevent the spread of disease-causing organisms. Interviews with staff confirmed that the commode should have been cleaned after use, and both the LPN and the DON acknowledged that the presence of the brown substance indicated the commode was not properly cleaned. The facility's policy, revised 7/1/25, specifically states that a safe, clean, comfortable, and homelike environment must be maintained, including the cleanliness of resident care equipment used for activities of daily living.
Late Reporting of Investigation Results for Alleged Misappropriation
Penalty
Summary
The facility failed to ensure that the results of all investigations of alleged violations were reported to the resident or their designated representative and to other officials, including the State Survey Agency, within the required 5 working days. Specifically, an incident involving the alleged misappropriation of $160.00 belonging to a resident was reported to the State Agency on the same day the facility became aware of the allegation. However, the results of the internal investigation were not submitted to the State Agency until 6 working days after the initial report, exceeding the required timeframe. According to facility policy, the Administrator is responsible for confirming that the initial report was received by government agencies and for reporting the results of the investigation within 5 working days. During an interview, the Nursing Home Administrator acknowledged that the results were reported late, attributing the delay to waiting for a response from the resident's daughter regarding the missing money. The surveyor confirmed that the investigation results were not submitted within the required period, as outlined in both facility policy and state regulations.
Failure to Assess and Document Bed Rail Use and Entrapment Risk
Penalty
Summary
The facility failed to ensure that alternatives were attempted prior to the installation and use of bed rails, including side rails and enabler bars, for multiple residents. There was no system in place to assess the risk of entrapment between the mattress and side rail, and the facility did not identify or recognize that the use of side rails with air mattresses increases the risk for entrapment. Documentation was lacking for assessments, risks and benefits discussions, alternatives tried, measurements, and informed consent for the use of side rails for several residents, both cognitively intact and impaired, some of whom had activated powers of attorney. Surveyors observed numerous residents using air mattresses with side rails or enabler bars without evidence of prior assessment or documentation. Interviews with facility staff, including the DON, Maintenance Director, and PTA, confirmed that there was no process or assessment in place for side rails prior to a specific date. Staff also indicated that side rails were often left on beds after resident discharge and used for subsequent residents without evaluation. In several cases, residents or their representatives reported not being informed of the risks and benefits or being asked for consent prior to the use of side rails or enabler bars. Specific examples included residents with significant mobility impairments, cognitive deficits, and histories of falls who were observed with air mattresses and side rails or enabler bars, but without any documentation of risk assessment, alternatives attempted, or informed consent. In some cases, gaps between the mattress and side rails were observed to be large enough to pose a risk of entrapment. The facility's own policy and FDA recommendations regarding bed rail safety and the increased risk of entrapment with air mattresses were not followed prior to the surveyors' findings.
Failure to Prevent and Manage Pressure Injuries Leading to Harm and Immediate Jeopardy
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent and manage pressure injuries for three residents at risk, resulting in the development and worsening of pressure ulcers. One resident, with a history of immobility and poor nutrition, developed an unstageable pressure injury on the sacrum that progressed to a stage IV infected wound, requiring hospital transfer. The facility did not implement timely or aggressive interventions, failed to update the care plan with new wound information, and did not ensure consistent repositioning or timely provision of an air mattress as ordered. Documentation of repositioning was inconsistent, and staff did not consistently document refusals or provide risk/benefit education regarding repositioning. Another resident at high risk for pressure injuries due to contractures and positioning developed an unstageable pressure injury on the heel. Staff failed to implement offloading interventions until after the injury was discovered, did not identify or assess the new wound in a timely manner, and failed to notify the provider. The resident reported that staff were not repositioning him every two hours and had not discussed the risks and benefits of repositioning refusals. Observations revealed improper wound coverage and lack of prompt communication when dressings were found off. Additionally, staff were observed performing wound care without following proper infection control protocols, including failure to use required PPE and perform hand hygiene between glove changes. There were delays in obtaining wound cultures and confusion regarding the use and documentation of pressure-relieving mattresses. Interviews with staff revealed gaps in knowledge and inconsistent practices related to pressure injury prevention, care planning, and documentation. These failures led to actual harm and, in one case, immediate jeopardy for the affected residents.
Removal Plan
- Care Plan review to ensure robust and individualized interventions are in place and appropriate for residents' current condition, will be reviewed for changes if applicable
- Review documentation in resident's medical record as it relates to turn and repositioning by staff for opportunity, updates to PCC (EMR) Tasks / POC charting to reflect current documentation needs
- Upon resident's return, the need for a Risk vs. Benefit discussion will be evaluated based on residents' condition and completed if applicable at time of readmission
- Skin Evaluations completed on active in-house residents by Director of Nursing and/or Designee with no additional significant results
- Braden Risk Evaluations completed and reviewed on active in-house residents by the Director of Nursing and/or Nursing Management
Failure to Implement and Maintain Effective Infection Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in the development and transmission of multi-drug resistant organisms (MDROs) among residents. Multiple residents tested positive for extended-spectrum beta-lactamase (ESBL)-producing organisms, with at least four residents on the same hallway developing infections within a short period. The facility did not implement appropriate transmission-based precautions for these residents, as required by both facility policy and CDC guidelines. Documentation showed that no isolation precautions were put in place, and the Infection Preventionist could not provide evidence or recall if such measures were implemented. Staff were not adequately educated or aware of the necessary precautions for residents with MDROs, and there was no documentation of staff training or outbreak response specific to these cases. Hand hygiene practices were not followed according to standards of practice. Staff were observed failing to perform hand hygiene before and after resident care, after glove changes, and before handling clean or soiled dressings. During wound care and bed baths, staff did not use required personal protective equipment (PPE) such as gowns, and did not perform hand hygiene at critical points. In one instance, a staff member used a cell phone during care without changing gloves or performing hand hygiene, and continued care with contaminated gloves. Additionally, soiled linens and clothing were improperly handled, being thrown on the floor rather than placed in designated containers, contrary to facility policy and infection control standards. The facility also failed to ensure that infection control policies were reviewed annually, as required by their own procedures. When asked, facility leadership could not provide evidence of annual policy review. Furthermore, staff did not offer or facilitate hand hygiene for residents before meals, and cited lack of available hand sanitizer as a reason. Interviews with staff revealed gaps in knowledge and training regarding infection prevention, PPE use, and hand hygiene protocols. These failures contributed to the spread of MDROs and placed residents at risk for further harm.
Failure to Follow Physician Orders and Monitor Residents Leads to Harm
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for three residents, resulting in actual harm for two and potential for more than minimal harm for one. For one resident with congestive heart failure (CHF) and protein calorie malnutrition, the facility did not complete required RN assessments or monitor for complications related to CHF and malnutrition. The resident was on diuretic therapy, but staff failed to weigh the resident as ordered, did not notify the physician of significant weight changes, and did not assess the resident's response to diuretic therapy. The resident experienced significant weight fluctuations, including a loss of 13.2 lbs over six days and a gain of 4 lbs in one day, without appropriate clinical response or physician notification. This resident was ultimately hospitalized for acute exacerbation of CHF, requiring IV diuresis and further medical intervention. Another resident was prescribed an anticoagulant medication but did not receive adequate monitoring for side effects. When the resident experienced a nosebleed that could not be stopped and a drop in blood pressure, staff failed to complete an RN assessment or promptly notify the physician. The resident was not sent to the emergency department until the following morning, after which hospitalization was required for blood transfusion and intravenous vitamin K administration. Documentation showed that blood pressure readings were low prior to the bleeding event, but no further assessment or provider notification occurred at those times. Additionally, the facility did not follow physician orders for wound care treatment for a third resident. The report details that staff did not adhere to established protocols and physician directives for monitoring, documentation, and timely notification of significant changes in condition, as outlined in facility policies. These failures resulted in missed opportunities to intervene and prevent harm, as evidenced by the hospitalizations and clinical deterioration of the affected residents.
Failure to Follow Food Storage and Dishwashing Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Surveyors observed that nutritional supplements, specifically Sysco Mighty Shakes, were completely thawed in the kitchen refrigerator without any thaw dates noted, despite the product label requiring disposal within 14 days of thawing. The Dietary Manager confirmed that the shakes had not been dated when removed from the freezer. Additionally, the facility's low-temperature, sanitizing dishwasher was documented to have a chlorine PPM of only 10, well below the required 50-100 PPM, and dietary staff did not report this issue as required. The Certified Dietary Manager was not notified of the low PPM reading at the time it occurred.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Garbage and refuse were not disposed of properly at the facility. During an observation in the main exterior garbage area, a surveyor and the Dietary Manager found 13 used gloves scattered around two dumpsters, two bags of garbage on the ground (one partially under a dumpster), and what appeared to be hundreds of cigarette butts on the ground. The Dietary Manager confirmed during interview that the garbage had been present for over a week and needed to be removed. This deficiency had the potential to affect all 66 residents in the facility.
Deficient Facility Assessment Fails to Address Resident Needs and Staff Competencies
Penalty
Summary
The facility failed to ensure its facility-wide assessment accurately reflected the resident population and the resources necessary to provide competent care during both routine operations and emergencies. The assessment did not include all relevant details, such as the presence of residents whose primary languages were Spanish and Russian, despite the facility only noting English and Hmong in its documentation. Staff were observed to be unable to communicate effectively with residents who spoke Spanish, Hmong, or Russian, and were unaware of how to use interpreter services, resulting in communication barriers that could impact care delivery. The facility assessment also indicated the ability to care for residents receiving dialysis, but staff demonstrated a lack of competency in managing dialysis-related emergencies. Certified Nursing Assistants (CNAs) interviewed were unable to describe appropriate actions to take if a resident was bleeding from a dialysis fistula, stating only that they would get a nurse, and did not mention applying pressure to stop bleeding. Additionally, the facility failed to implement and document appropriate interventions for residents with pressure injuries, as evidenced by two residents developing advanced stage pressure injuries without timely or adequate interventions, assessment, or communication with providers. Further deficiencies were noted in infection prevention and control practices, where the Infection Preventionist failed to recognize and control an ESBL outbreak, and staff did not follow proper hand hygiene or transmission-based precautions. The facility assessment also did not address the use of equipment such as bed rails and enabler bars, nor did it ensure staff were educated on their safe use or assessed residents for risks associated with these devices. Multiple residents were observed with such equipment in use without proper assessment, consent, or documentation of alternatives. These findings demonstrate that the facility assessment did not comprehensively address the needs of the resident population or the competencies required of staff.
Failure to Ensure Monthly Physician Review and Signature of Orders
Penalty
Summary
The facility failed to ensure that physicians reviewed residents' total program of care and signed monthly physician orders as required for 9 out of 11 residents reviewed. Specifically, multiple residents did not have signed physician orders for several consecutive months, with some missing signatures for up to five months. The facility's policy requires physicians to review and sign all orders and to review the resident's total program of care, including medications and treatments, at each visit. However, documentation showed that these requirements were not met for the majority of sampled residents. During interviews, the Director of Nursing acknowledged that the electronic health record system was not configured to notify physicians of the need to sign monthly orders, and some unsigned orders might be misplaced in medical records. Both the Director of Nursing and the Interim Nursing Home Administrator confirmed that they expected every resident to have signed physician orders monthly, but this was not consistently occurring. The deficiency was identified through record review and staff interviews, with specific examples provided for each affected resident.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for four out of five Certified Nursing Assistants (CNAs) reviewed, as required by both federal regulations and the facility's own policy. Specifically, CNAs with hire dates ranging from September 2021 to December 2022 did not have documented annual performance evaluations. Interviews with the Director of Nursing and the Interim Nursing Home Administrator confirmed that annual evaluations are expected for all CNAs, and that these evaluations were not up to date for the staff reviewed. The deficiency was identified through record review and staff interviews, with no evidence of completed annual evaluations for the identified CNAs.
Failure to Maintain Clean and Homelike Resident and Shower Environments
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, as required by policy. One resident's room was observed to have a footboard and wall covered with dried particles, which were not clean or homelike. This resident, who is severely cognitively impaired and has a history of behaviors such as smearing food on walls, was unable to answer questions about her environment. Despite a previous grievance from her health care power of attorney regarding the cleanliness of her room, surveyors observed ongoing issues with cleanliness during their visit. Staff confirmed that the footboard and wall were not clean and acknowledged that these areas should be free from debris. Two other residents, both cognitively intact, expressed concerns about the cleanliness of the shower rooms. One resident reported being unable to shower due to the shower being too cold and dirty, with visible residue on the shower head, floor, and toilet. The other resident described the showers as "disgusting," with trash on the floor and unclean fixtures, leading her to avoid showering at the facility. Surveyors confirmed these observations, noting that the shower rooms were unkept, with visible black and brown substances, residue, and grime on various surfaces, including shower chairs and fixtures. Further observations revealed that five out of six shower rooms in the facility were not maintained in a clean or orderly manner. Issues included blinking lights, loud fans, missing wall fixtures, and unclean shower chairs. Staff interviews indicated that CNAs are expected to pick up shower rooms after each use and that housekeeping is responsible for deep cleaning, but these practices were not consistently followed, resulting in an environment that did not meet the standards for cleanliness and comfort as outlined in facility policy.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were clinically assessed and determined to be appropriate for self-administration of medications, as required by facility policy. In one instance, a resident with severe cognitive impairment and a BIMS score of 0 out of 15 was observed being left alone in the dining room with a shake containing multiple crushed medications. The LPN responsible for medication administration did not remain with the resident or ensure the medications were taken, and there was no assessment or order for self-administration of medications for this resident. The Director of Nursing confirmed that the resident did not have a self-administration assessment and was not able to self-administer medications. In another case, a cognitively intact resident was found in her room with a cup of multiple medications left on her bedside table for her to take independently. The RN stated that the medications had been left after breakfast and that the resident could take her own medications without supervision. However, there was no documentation or assessment on file to support that the resident had been evaluated and approved for self-administration of medications. The Director of Nursing confirmed that residents without a self-administration assessment should not be left alone with their medications.
Failure to Provide Culturally and Linguistically Appropriate Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of a resident who speaks only Spanish. The resident, who has diagnoses including cerebral infarction and major depressive disorder, was observed to spend most of her time either lying in bed or sitting in the dining area with limited engagement in meaningful activities. The care plan and activity evaluation listed preferences such as resting, watching TV, listening to music, and coloring, but these activities were not tailored to her language or cultural needs. Staff interviews revealed a lack of awareness of the resident's preferences, and activities provided did not accommodate her Spanish language or cultural background. Observations showed the resident often appeared restless, bored, or frustrated, and was seen talking out loud in Spanish without staff understanding or engaging with her. The television was not set to Spanish closed captioning, and music provided was not in Spanish. During group activities, staff did not use available translation tools to communicate with the resident, and she was left with materials she did not use, while other residents participated in activities she could not access due to the language barrier. Staff acknowledged that the resident was the only Spanish-speaking individual in the facility and that activities were not adapted for her needs. Family interviews indicated the resident felt isolated, misunderstood, and expressed feelings of loneliness and frustration due to the lack of communication and culturally appropriate activities. The family also reported that the resident enjoyed activities such as cooking and household chores, which were not offered. Staff and social worker interviews confirmed that translation services were rarely used during activities, and there was no consistent effort to provide Spanish-language entertainment or culturally relevant engagement. The facility's failure to individualize the activity program for the resident's language and cultural needs resulted in unmet psychosocial and emotional needs.
Failure to Provide Safe and Appropriate Dialysis Care and Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for a resident requiring such services. The resident, who was cognitively intact and diagnosed with end stage renal disease among other conditions, did not have a care plan that addressed dialysis-specific needs, including monitoring of the vascular access port, assessment for complications, or emergency procedures for bleeding from the dialysis fistula. Physician orders and facility policy required monitoring of the access site for signs of infection, edema, and bleeding every shift, as well as ongoing evaluation and documentation of weights and vital signs before and after dialysis treatments. However, documentation was inconsistent, with multiple instances of missing vital signs, weights, and incomplete monitoring records in both the facility's records and the dialysis communication log. Interviews with the resident confirmed that staff did not routinely take weights, monitor vital signs, or assess the vascular access port in relation to dialysis treatments. Review of the facility's records showed significant gaps in documentation of vital signs and weights over several months, and the care plan lacked any focus or interventions related to dialysis care. The facility's own policy outlined the need for ongoing assessment and monitoring, but these were not consistently implemented for the resident. Staff interviews revealed a lack of knowledge and preparedness regarding emergency management of bleeding from a dialysis fistula. Certified Nursing Assistants (CNAs) stated they would leave the resident to get a nurse if bleeding was observed, without applying pressure or taking immediate action. Licensed Practical Nurses (LPNs) gave inconsistent responses about holding pressure and sending the resident to the hospital, and the Director of Nursing acknowledged that staff training on dialysis care likely needed to be redone. Overall, the facility did not ensure that the resident received care and services consistent with professional standards of practice, physician orders, and the resident's needs and preferences.
Failure to Ensure Timely Provider Visits and Proper Alternation Between Physician and Extender
Penalty
Summary
The facility failed to ensure that residents were seen by a physician or physician extender (NP, PA) at the required intervals for three of eleven residents reviewed. Specifically, one resident did not have documentation of provider visits for five consecutive months, while another lacked a provider visit for one month and did not have alternating visits between a physician and physician extender as required. A third resident also did not have documentation of a provider visit for one month. The facility's policy requires that a progress note be present for each physician visit, including the date, time, and any new orders or discussions, and that required visits in SNFs may alternate between physician and physician extender after the initial visit. Interviews with the Director of Nursing and the Interim Nursing Home Administrator confirmed that each resident should be seen by the appropriate provider in a timely manner. However, record reviews indicated that this standard was not met for the identified residents, as there were missing or improperly alternated provider visits within the specified timeframes.
Failure to Provide Culturally Competent Communication for Non-English Speaking Residents
Penalty
Summary
Nursing staff at the facility did not demonstrate appropriate cultural competencies to communicate effectively with residents who have limited English proficiency (LEP), despite the facility having policies and resources such as an interpreter line and translation devices. For three residents with communication needs—one Spanish-speaking, one Hmong-speaking, and one Russian/Ukrainian-speaking—staff were observed and interviewed as being unable to communicate adequately in the residents' primary languages. Staff often relied on body language, gestures, or ad hoc translation tools like Google Translate or a translation ball, rather than using the facility's interpreter services as outlined in the care plans and facility policy. For the Spanish-speaking resident with diagnoses including cerebral infarction and major depressive disorder, staff were unable to understand or respond to her verbalizations during care and activities. The resident was observed becoming frustrated and agitated due to the lack of effective communication. Interviews with staff revealed that they did not consistently use the interpreter line and often could not understand the resident's needs or requests. The resident's family member reported that she felt isolated and misunderstood, and that her preferences for activities and entertainment in Spanish were not accommodated. The Hmong-speaking resident, who is severely cognitively impaired, also did not receive communication in his preferred language. Staff communicated with him primarily through hand signals and body language, and documents provided to him were only in English. Similarly, the Russian/Ukrainian-speaking resident, also severely cognitively impaired, had staff who attempted to use posted common phrases or asked other staff for help, but did not utilize the interpreter line. In all cases, despite the facility's policy and care plan interventions specifying the use of qualified interpreters and language assistance services, staff did not follow these procedures, resulting in a failure to provide meaningful communication and culturally competent care.
Failure to Follow Antibiotic Stewardship Program and Monitor Antibiotic Use
Penalty
Summary
The facility failed to follow its antibiotic stewardship program for three residents, as evidenced by inappropriate antibiotic use and lack of required monitoring and documentation. One resident was treated with antibiotics for a urinary tract infection (UTI) despite laboratory results not supporting the diagnosis, and the Infection Preventionist (IP) confirmed that the resident did not meet criteria for a UTI but was treated due to family request. There was no documentation of education provided to the family regarding the risks and benefits of antibiotic use in this case. Two other residents received prophylactic antibiotics without appropriate justification or documentation. One resident was given nitrofurantoin for chronic UTI prevention, and the other received doxycycline for a skin condition, initially documented as prophylactic use for a pressure ulcer. In both cases, the IP did not have documentation of discussions with the primary care provider (PCP) regarding the risks, benefits, or appropriateness of prophylactic antibiotic use, nor was there evidence of adherence to the facility's antibiotic stewardship protocols. Interviews with the IP and Director of Nursing (DON) revealed that neither had engaged in or documented required conversations with prescribing practitioners about antibiotic stewardship or the appropriateness of prophylactic antibiotic use. The facility's policy requires monitoring, documentation, and education related to antibiotic use, but these steps were not followed for the residents in question, leading to the identified deficiency.
Failure to Notify Physician of Significant Skin Change
Penalty
Summary
The facility failed to immediately notify and consult with a resident's physician when a significant change in the resident's physical condition occurred. Specifically, a resident with a history of paranoid schizophrenia and mild cognitive impairment, who was cognitively intact per recent assessment, was sent to the emergency department (ED) due to a change in condition. At the ED, the resident was found to have a severe candidal rash around the suprapubic catheter and into the bilateral groin, and was diagnosed with Candidiasis intertrigo, for which Nystatin was prescribed. Despite the presence of this severe rash, the facility did not document any changes to the resident's skin condition around the suprapubic catheter, nor did they notify the provider regarding the rash. The facility's policy requires prompt notification of the resident, physician, and representative when a change in condition occurs that requires a new form of treatment. The Director of Nursing confirmed that staff would be expected to notify the provider of such a rash, but this did not occur in this instance.
Failure to Document and Resolve Resident Grievances per Policy
Penalty
Summary
The facility failed to make prompt and thorough efforts to document, investigate, and resolve grievances for one resident, as required by its own grievance policy. The policy mandates that the Grievance Official must record information about the grievance, document steps taken to resolve it, and issue a written decision to the resident or representative at the conclusion of the investigation. However, in multiple instances, the facility did not complete or document appropriate interviews, audits, education, or follow-up with the resident or her family after grievances were reported. The resident involved had diagnoses including type 2 diabetes mellitus, heart failure, depression, and malignant neoplasm of the transverse colon, and was cognitively intact at the time of the incidents. Grievances reported included issues with oxygen setup and communication, delayed call light response, inability of the family to contact staff in the evening, and frustration with CNA follow-up. In each case, the facility's documentation was incomplete: there was a lack of evidence of staff education, insufficient or undocumented interviews, and no written communication of investigation results or confirmation of complainant satisfaction with the resolution. Interviews with facility staff revealed that only involved staff were interviewed, education was not documented or provided, and follow-up with the resident or family was either not conducted or not documented. The facility also did not provide written decisions to the complainants as required, nor did it document whether the complainants agreed with the outcomes. Requests for additional documentation of staff education, interviews, and communication with complainants were not met, further evidencing the facility's failure to comply with its grievance policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
Two residents were affected by inaccurate Minimum Data Set (MDS) assessments. In the first case, a resident with diagnoses including malignant neoplasm of the anus, type 2 diabetes mellitus, and neuropathy was incorrectly documented in the MDS as receiving hospice services. The resident, who was cognitively intact, confirmed during an interview that he was not receiving hospice care and had not signed up for such services. The MDS Coordinator and the Director of Nursing both confirmed that the resident was never on hospice and that the entry was a clerical error. The MDS Coordinator stated that she relies on information from the Interdisciplinary Team (IDT) meetings and notifications from hospice providers to update the MDS, but in this instance, no such notification was received. In the second case, another cognitively intact resident was documented in the MDS as having an unhealed pressure injury at stage 1 or higher. Upon interview, the resident reported only having a wound on her right shin, which was confirmed through record review to be a venous stasis ulcer, not a pressure injury. There was no evidence in the medical record to support the presence of a pressure injury as reported in the MDS. The Director of Nursing confirmed that the MDS should accurately reflect the resident's actual medical diagnoses and treatment, which did not occur in these cases.
Failure to Document and Provide Scheduled Showers for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia, did not receive the necessary assistance with activities of daily living (ADLs), specifically personal hygiene. The resident was scheduled to receive showers on Mondays and Thursdays and required assistance for bathing. However, there was no documentation that the resident was offered, received, or refused showers on several scheduled dates. The care plan indicated that the resident sometimes refused care, and education was provided to the resident and their activated Power of Attorney for Health Care (APOAHC) regarding these refusals. Despite this, the facility failed to document any offers or refusals of showers on the specified dates. The lack of documentation was identified during a review of the resident's records and was also a concern raised by the resident's APOAHC, who filed a grievance about the resident not receiving regular showers. The Director of Nursing confirmed that staff are expected to re-approach residents up to three times and document refusals both in the electronic health record and on paper, but this process was not followed for the dates in question. The resident was unable to communicate about their shower schedule when interviewed, further emphasizing the need for staff to ensure and document the provision or refusal of care.
Failure to Implement Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to maintain a resident's environment free from accident hazards and did not implement care plan interventions to prevent accidents. The resident, who was severely cognitively impaired with diagnoses including Alzheimer's disease, stroke, anxiety disorder, and seizures, was care planned for fall risk interventions such as keeping the bed in the lowest position, ensuring fall mats were at the bedside, and having the call light within reach. However, observations revealed the resident's bed was in the highest position, fall mats were missing, and the call light was not accessible. Staff confirmed the bed was broken and could not be lowered, and they were unaware of the location of the fall mats. The maintenance director was not informed about the broken bed, and nursing staff acknowledged that required fall interventions were not in place. Interviews with the resident's power of attorney, certified nursing assistants, the maintenance director, a registered nurse, and the director of nursing confirmed that the interventions outlined in the resident's care plan were not followed. The facility's policy required the environment to be as free of accident hazards as possible and for staff to implement interventions to reduce risks, but these measures were not adhered to for this resident.
Catheter Bag Improperly Placed on Floor
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed to have their catheter bag uncovered and resting in direct contact with the floor. This observation was made by a surveyor, who noted that the catheter bag was not properly maintained according to infection control guidelines. Both a CNA and the Director of Nursing confirmed that the catheter bag should not be in contact with the floor. The facility's care plan for the resident included monitoring for signs and symptoms of urinary tract infection (UTI) and ensuring proper catheter care, but these interventions were not followed as evidenced by the improper placement of the catheter bag. The resident involved had a history of cerebral infarction, bilateral knee contractures, reduced mobility, and osteoarthritis, and was cognitively intact according to the most recent assessment. The care plan specifically addressed the need for appropriate catheter care to prevent UTIs, including keeping the catheter and collecting tube free from kinking and ensuring the collection bag remained below the bladder and off the floor. The failure to adhere to these protocols resulted in the deficiency cited by the surveyor.
Inadequate Post-Fall Monitoring and Documentation
Penalty
Summary
The facility failed to ensure adequate supervision, monitoring, and evaluation for two residents after they experienced falls. Resident R2, who has diagnoses including Parkinson's disease, anxiety disorder, dementia, muscle weakness, and polyneuropathy, had an unwitnessed fall. The facility did not document post-fall clinical findings or assess the effectiveness of existing fall interventions, nor did they revise R2's fall care plan. Similarly, Resident R3, with diagnoses including encephalopathy, type 2 diabetes, and anxiety, also had an unwitnessed fall. The facility again failed to document relevant post-fall clinical findings or evaluate the appropriateness of R3's fall interventions. Interviews with facility staff, including LPNs and the Director of Nursing, revealed that the facility's policy requires monitoring and documentation of post-fall clinical findings for at least 72 hours, including neurological evaluations and vital signs. However, the facility was unable to provide documentation of such monitoring for R2 and R3. The Director of Nursing confirmed the expectation for progress notes to be maintained for 72 hours post-fall, but this was not done for the two residents in question.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for food storage and preparation, potentially affecting all 64 residents. During an inspection, a surveyor observed a layer of dust on the wall in the dry food storage area above unsealed food items, which could lead to contamination. Additionally, food items in the reach-in coolers were found to be either undated or past their use-by dates, contrary to the facility's policy requiring all food to be labeled and dated. The presence of nicked spatulas in the utensil drawer and an unclean microwave with dried-on particles further highlighted the lack of adherence to cleanliness standards. The surveyor also noted that staff's partially consumed personal water bottles were stored in the refrigerator alongside residents' food, which is against the facility's policy. This practice poses a risk of cross-contamination between staff and residents' food items. Furthermore, residents were observed obtaining ice from the ice chest themselves, which could lead to contamination. Interviews with staff and residents confirmed that residents frequently accessed the ice chest without supervision, and staff acknowledged that this practice could contaminate the ice. One resident, who is cognitively intact and independent in daily activities, reported having to find the ice chest to fill his cup with ice, indicating a lack of proper monitoring by staff. Another resident provided photographic evidence of residents accessing the ice chest. The Director of Nursing was informed of these observations and acknowledged that residents obtaining ice themselves could lead to contamination.
Failure to Maintain a Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations made by the surveyor. On one occasion, a bag of soiled linen and a bag of trash, including soiled briefs, were left unattended in the middle of a hallway where 12 residents resided. Staff members were observed walking past the bags without addressing them until a CNA eventually removed them. This indicates a lapse in maintaining cleanliness and safety in common areas. Additionally, specific incidents in residents' rooms further highlighted the deficiency. A dried sticky substance was found on a resident's floor, covered with towels, after a staff member accidentally spilled soda and failed to clean it properly. Another resident's room had a bag of soiled, wet linen left on the floor, which a CNA acknowledged but did not immediately remove. These incidents demonstrate a lack of prompt and adequate response to maintaining cleanliness and safety in residents' personal spaces.
Failure to Notify Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of transfers or discharges for seven residents reviewed for such events. The facility's policy requires that transfer or discharge notices be provided to the resident, their representative, and the Ombudsman in a language and manner they can understand, with evidence maintained of such notifications. However, the facility did not provide evidence that these notifications were sent to the Ombudsman for any of the seven residents involved. The deficiency was identified through interviews and record reviews. The social worker, identified as SW D, was unable to provide documentation of the required notifications to the Ombudsman. SW D acknowledged that the notifications should have been done but confirmed that they had not been completed. This lack of documentation and failure to notify the Ombudsman was consistent across all seven residents reviewed, indicating a systemic issue in the facility's handling of transfer and discharge notifications.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide the required written bed-hold notices to residents or their representatives when residents were transferred to the hospital. This deficiency was identified for six residents who were transferred multiple times without receiving the necessary documentation. The facility's policy, dated July 10, 2024, mandates that a written notice specifying the duration of the bed-hold policy and information about the resident's return to the next available bed must be provided at the time of transfer. In cases of emergency transfers, the notice should be given within 24 hours. However, the facility did not adhere to this policy, as evidenced by the lack of bed-hold notices for residents R13, R26, R29, R31, R36, and R49 during their hospital transfers. The deficiency was further confirmed during an interview with the facility's social worker, who was unable to provide the required bed-hold documentation when requested by the surveyor. The social worker acknowledged that the notices should have been given to the residents but admitted that they were not completed. This oversight indicates a failure in the facility's process to ensure compliance with its own bed-hold policy, resulting in a lack of communication with residents and their representatives regarding their rights and the facility's obligations during hospital transfers.
Failure to Complete PASARR Level II Evaluations
Penalty
Summary
The facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II evaluations for residents who stayed longer than 30 days, despite having conditions that required such assessments. This deficiency affected four residents, all of whom had serious mental disorders or were on psychotropic medications, necessitating a PASARR Level II evaluation. The facility's policy mandates coordination with the PASARR program to ensure appropriate care for individuals with mental disorders or intellectual disabilities, but this was not adhered to in these cases. The residents involved had various diagnoses, including delusional disorders, dementia, major depressive disorder, anxiety disorder, post-traumatic stress disorder, schizophrenia, and other serious mental health conditions. Despite these diagnoses and the use of psychotropic medications, the facility did not provide evidence of completing the necessary PASARR Level II screens after the residents exceeded the 30-day exemption period. Interviews with the facility's social worker and Director of Nursing confirmed that only PASARR Level I screens were completed, and the required Level II evaluations were not conducted.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide scheduled showers to four residents, leading to a deficiency in the care and assistance for activities of daily living (ADLs). Resident R25, who has intact cognition, reported missing showers due to staff not offering them or not having time. Her care plan required assistance with bathing on Tuesday evenings, but documentation showed inconsistencies, with several instances of no documentation or refusals without reapproach. Resident R37, with severely impaired cognition, also reported not receiving scheduled showers. Her care plan required assistance every Wednesday morning, but documentation revealed missed showers and instances where no documentation was provided. The Director of Nursing and Nursing Home Administrator acknowledged that staff should document refusals and reapproach residents if unavailable. Resident R9, who rarely speaks and is never understood, had a care plan requiring assistance with bathing. Documentation showed missed showers and lack of documentation on several dates. Resident R266, with intact cognition, reported not receiving showers and had only one documented shower over several weeks. A CNA admitted to not documenting refusals and being unaware of the resident's shower schedule, contributing to the deficiency.
Inadequate Supervision and Safety Measures for Residents at Risk
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for residents at risk of elopement and smoking hazards. Resident R17, who has moderate cognitive impairment and is at risk for elopement, did not have a code alert bracelet as required by the physician's order and care plan. Multiple staff members, including LPNs and RNs, were aware of the missing code alert bracelet but failed to replace it, leading to a situation where R17 left the facility with her husband without triggering the elopement alarm. The staff's misunderstanding of the code alert system and failure to follow procedures contributed to this deficiency. Similarly, Resident R13, also at risk for elopement, returned from the hospital without a code alert bracelet. The staff did not promptly replace the bracelet upon R13's return, contrary to the facility's policy and the expectations set by the Director of Nursing. This oversight was attributed to a lack of immediate action by the nursing staff, who were aware of the requirement to replace the code alert bracelet but did not do so in a timely manner. Additionally, the facility failed to secure a medication cart, which was left unlocked and unattended with medications visible and accessible. This posed a potential risk to all residents on the hall. Furthermore, Resident R219, a smoker, had conflicting care plan instructions regarding supervision while smoking. The care plan and CNA Kardex indicated both supervised and unsupervised smoking, leading to confusion among staff about the appropriate level of supervision required. The Director of Nursing was unaware of R219's smoking status, highlighting a lack of communication and clarity in the resident's care plan.
Deficiency in Trauma-Informed Care for Residents
Penalty
Summary
The facility failed to ensure that residents with a history of trauma, mental disorders, or psychosocial adjustment difficulties received appropriate treatment and services. This deficiency was identified for four residents (R11, R48, R17, and R21) out of a sample of 21. The facility's policy on Trauma Informed Care was not adequately implemented, as evidenced by the lack of personalized care plans that included known triggers, goals, and interventions related to the residents' trauma histories. Resident R11, who reported experiencing childhood trauma, did not have a comprehensive care plan that addressed her specific triggers, such as discomfort with male caregivers. Despite her intact cognition and ability to communicate her needs, staff members, including CNAs and RNs, were unaware of her trauma history and specific triggers. The social worker acknowledged that the assessment tools used did not capture individualized triggers or interventions, and the Director of Nursing recognized the need for a dedicated care plan addressing R11's trauma. Similarly, residents R48, R17, and R21 had care plans that were not individualized to their trauma histories. R48's care plan lacked details on her traumatic experiences and specific interventions, while R17's care plan did not incorporate recommendations from mental health services. R21's care plan was missing information on the type of trauma experienced and personalized interventions. The facility's failure to incorporate trauma-informed care into the residents' care plans resulted in a lack of appropriate treatment and services for these individuals.
Infection Control Breaches in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, resulting in multiple breaches of standard transmission-based precautions. During catheter care for a resident, a registered nurse did not wear a gown, failed to use a proper barrier for dirty washcloths, and neglected to perform hand hygiene at the appropriate times. Despite the presence of proper signage and available PPE, the nurse was unaware of the enhanced barrier precautions required for the resident, indicating a lapse in communication and training. In another instance, the infection preventionist did not follow proper hand hygiene protocols during wound care for a resident. The infection preventionist failed to change gloves and perform hand hygiene after touching potentially contaminated surfaces and before handling clean dressings. This oversight was acknowledged by the infection preventionist during an interview, highlighting a deviation from the facility's hand hygiene policy. Additional breaches were observed during personal care and medication administration. A CNA did not use enhanced barrier precautions while providing care to a resident with an indwelling medical device, mistakenly believing the precautions applied to the resident's roommate. Furthermore, a nurse contaminated multiple surfaces with gloves used during a blood sugar test, and an LPN placed wound care supplies directly on the floor without a barrier, both actions contrary to infection control standards.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure that a resident, identified as R220, was treated with respect and dignity, specifically regarding their right to privacy during personal care. R220, who is cognitively intact and requires assistance with activities of daily living due to conditions such as Type 2 Diabetes Mellitus and mobility issues, reported that a non-licensed staff member, the scheduler, was present in the room during personal care activities. This presence was not authorized by the resident, thus violating their right to privacy and dignity as outlined in the facility's Bill of Resident Rights. The scheduler, whose CNA license had lapsed, admitted to being in the room to observe CNAs as part of the care with pairs program, despite not having the resident's explicit permission. The Director of Nursing confirmed that it was not acceptable for non-certified staff to be present during such care activities. The resident expressed concerns that the facility placed them on care with pairs due to their complaints and communication with state authorities, further indicating a lack of respect for their rights and dignity.
Failure to Follow Grievance Process for Resident Complaints
Penalty
Summary
The facility failed to adhere to its grievance policy for two residents, R19 and R11, resulting in a deficiency. R19, who has moderate cognitive impairment and requires total assistance for activities of daily living, reported to a surveyor that staff were rough and manhandled him during care. Despite this report, no grievance was filed, and the Nursing Home Administrator (NHA) initially dismissed the concern as a customer service issue. The NHA's actions did not align with the facility's policy, which requires immediate escalation and investigation of grievances, especially those involving potential neglect or abuse. R11, who is cognitively intact, reported missing clothes to the laundry staff, but a grievance was not filed when all items were not recovered. The Housekeeping Supervisor was unaware of the missing clothes, and the process for handling such grievances was not followed. The Housekeeping staff member who was aware of the issue did not report it or complete a grievance form, contrary to the facility's policy that mandates reporting and filing a grievance if items are not found within a week. The facility's failure to follow its grievance process for both residents highlights a deficiency in handling resident complaints and concerns. The lack of proper documentation and escalation of grievances, as required by the facility's policy, indicates a systemic issue in addressing and resolving resident grievances promptly and effectively.
Failure to Timely Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation involving a resident, identified as R19, to the State Agency within the required timeframe. The facility became aware of the allegation on 10/7/24 but did not report it until 10/8/24 at 9:53 AM, exceeding the mandated reporting window. The facility's policy requires immediate reporting, but the Nursing Home Administrator (NHA) initially dismissed the concern as non-reportable, indicating a misunderstanding or disregard for the policy. R19, who has moderate cognitive impairment and is dependent on staff for personal care, expressed concerns to a surveyor about being handled roughly by staff, specifically mentioning "the black ones." Despite the resident's clear distress and request to speak with the administrator, the NHA sent a Unit Manager, who fit the description of the staff R19 was concerned about, to address the issue. This action further upset R19, who felt unsafe and intimidated, particularly after an interaction with the LPN who was perceived as hostile. The investigation into the allegation was not promptly initiated, and the facility's response was inadequate. The NHA did not document interviews or complete a grievance for R19, and the investigation was incomplete at the time of the surveyor's inquiry. The facility's failure to adhere to its own policies and state regulations regarding the timely reporting and investigation of abuse allegations resulted in a deficiency being cited.
Inadequate Investigation and Resident Protection in Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough investigation and adequate protection measures in response to an abuse allegation involving a resident, identified as R19. On October 7, 2024, R19 reported to a surveyor that staff were rough during care, specifically mentioning 'the black ones' as being rough with him during turning and repositioning. Despite this serious allegation, the facility did not provide evidence of measures taken to prevent further abuse to R19 and other residents. The facility's policy requires immediate investigation and protection of residents, but these steps were not adequately followed. The Nursing Home Administrator (NHA) initially perceived the issue as a customer service problem rather than a potential abuse case. The NHA sent a unit manager, LPN E, who fit the description of the alleged rough staff, to speak with R19, which was inappropriate given the circumstances. During this interaction, R19 expressed feeling unsafe and intimidated, particularly when LPN E, accompanied by RN F, confronted him in a hostile manner. Despite the ongoing investigation, LPN E was allowed to return to work, which compromised the safety of R19 and potentially other residents. The facility's investigation process was incomplete and poorly documented. The NHA admitted to not having completed the investigation and lacked written documentation of interviews conducted. The facility's failure to suspend LPN E until the investigation was concluded, and the lack of a grievance process for R19, further highlight the deficiencies in handling the abuse allegation. The facility's actions did not align with their policy to protect residents from harm during investigations, leading to a significant deficiency in resident care and safety.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. Specifically, the MDS assessment for one resident inaccurately indicated the presence of a Foley catheter, which the resident did not have. This discrepancy was identified during a surveyor's interview with the MDS coordinator, who initially was unsure about the resident's catheter status but later confirmed the error upon reviewing the resident's chart. The facility's policy requires comprehensive and accurate assessments to identify care needs and develop an interdisciplinary care plan, as mandated by federal regulations. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that staff are expected to complete MDS assessments accurately.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for two residents, R266 and R36, as required by their policy. R266, who was admitted with conditions including a cutaneous abscess of the neck and osteoarthritis, did not have a discharge care plan documented in her care plan. Despite being cognitively intact and aware of her impending discharge, R266 reported that no staff had discussed discharge planning with her. The social worker confirmed that discharge planning should start upon admission and should be documented, but it was not included in R266's care plan. For R36, the care plan contained inaccurate information, stating that the resident was ventilator dependent, had a tracheostomy, and had a catheter, none of which were true. R36 was admitted with metabolic encephalopathy and respiratory failure but was cognitively intact. The inaccuracies in the care plan were not corrected, and staff members, including the RN and LPN, were unsure about the frequency of care plan reviews and who was responsible for updating them. The DON stated that care plans should be reviewed with any change in condition, MDS completion, and monthly, but the inaccuracies in R36's care plan persisted. The facility's policy on comprehensive care plans emphasizes the need for person-centered care plans that include measurable objectives and timeframes, incorporating the resident's personal and cultural preferences. However, the failure to accurately document and update the care plans for R266 and R36 indicates a lack of adherence to this policy. The staff's uncertainty about the care planning process and responsibilities further contributed to the deficiencies identified by the surveyors.
Failure to Involve Residents in Care Planning Process
Penalty
Summary
The facility failed to ensure that residents or their representatives had the right to participate in the care planning process, as evidenced by the cases of two residents. One resident, who is cognitively intact, reported only attending one care planning meeting several months ago and expressed a desire to be more involved in her care planning. A review of her medical record revealed only one care conference note, which lacked input from nursing, therapy, or dietary staff, indicating it was not an interdisciplinary meeting. Another resident's medical record showed a care plan meeting over a year ago, with no subsequent meetings documented, despite the facility's policy requiring quarterly meetings. Interviews with facility staff, including the Social Worker, Director of Nursing, and Nursing Home Administrator, confirmed that care conferences should occur on admission and quarterly, involving an interdisciplinary team. However, it was acknowledged that the meetings for the two residents in question did not meet these requirements. The Social Worker admitted that the meeting for the first resident was not interdisciplinary, and no further meetings were documented. Similarly, the second resident had not had a care conference meeting in the current quarter, and documentation for a previous meeting was not provided.
Failure to Follow Physician Orders for Sleep Assessment and Medication Application
Penalty
Summary
The facility failed to adhere to physician orders and provide services as required in the person-centered care plan for two residents. For the first resident, who has diagnoses including schizophrenia and severe cognitive impairment, the facility did not complete a sleep assessment or maintain a sleep log as ordered by the physician. Despite a telephone order from February 2024 to complete a 7-day sleep log and update the Nurse Practitioner, the medical record lacked any documentation of this assessment. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the sleep study was not conducted as required. In the second instance, the facility did not properly administer ketoconazole shampoo as prescribed for a resident with seborrheic dermatitis. The physician's order specified that the shampoo should be applied to the scalp, left for five minutes, and then rinsed off with water. However, the resident reported only receiving the treatment a couple of times, and an LPN admitted to using damp towels instead of water to rinse the shampoo, contrary to the order. The Director of Nursing confirmed that the use of damp towels does not constitute a proper rinse, indicating a failure to follow the prescribed treatment protocol.
Failure to Conduct Proper Assessments During Change in Condition
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice when experiencing a change in condition. This deficiency was identified for one resident who experienced multiple hospitalizations due to changes in their respiratory and cardiac conditions. The facility's policy required an evaluation using the SBAR Communication Form and Progress Note Evaluation to ensure proper documentation and notification. However, the facility did not complete necessary respiratory and cardiac assessments prior to the resident's transfers to the hospital. The resident, who was cognitively intact, had diagnoses including metabolic encephalopathy and acute and chronic respiratory failure with hypercapnia. Despite experiencing unstable oxygenation status, shortness of breath, and crushing chest pain, the facility's documentation lacked vital signs and assessments of lung and heart sounds. Interviews with the RN and DON confirmed that staff were expected to perform and document thorough assessments during such changes in condition, but this was not done in the resident's case.
Failure to Provide Daily Diabetic Foot Care
Penalty
Summary
The facility failed to provide diabetic foot care in accordance with professional standards of practice for three residents diagnosed with type 2 diabetes. The facility's policy mandates daily diabetic foot checks to maintain skin integrity and foot health, as per the American Diabetes Association's guidelines. However, the Treatment Administration Records for the residents did not reflect daily foot checks. For one resident, the foot checks were not completed prior to the start date of the physician's order. Another resident's physician order specified foot assessments only on certain days, not daily, which is contrary to the standard practice. The third resident's physician orders did not include any directive for daily foot checks, and consequently, the Treatment Administration Record did not indicate such checks were being performed. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that diabetic foot checks are only conducted when they appear on the Treatment Administration Record, which is dependent on the presence of a physician's order. The Director of Nursing acknowledged that all diabetic residents should have daily foot checks, but the absence of specific orders in the residents' records led to the omission of this critical care practice. This oversight resulted in the facility not adhering to its own policy and the established standards of practice for diabetic foot care.
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Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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