Maryhill Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Niagara, Wisconsin.
- Location
- 501 Madison Ave, Niagara, Wisconsin 54151
- CMS Provider Number
- 525467
- Inspections on file
- 19
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Maryhill Manor during CMS and state inspections, most recent first.
Unsafe food storage and sanitation practices were identified when the kitchen logs for the 3-compartment sink and sanitizing buckets did not document sanitizer PPM or temperature, and the DM could not confirm staff were testing the solution as required. The surveyor also found resident food in the cooler that was improperly dated or undated, including sliced eggs, ham salad, and an open half head of cabbage, while the DM acknowledged concerns with labeling and discard timing.
Failure to Transmit Required Discharge MDS: The facility did not timely transmit a required Discharge MDS for a resident who was transferred to the hospital and did not return. Surveyors reviewed the resident’s record and MDS submissions and found no Discharge MDS had been sent. The MDSC confirmed the Discharge-Return Anticipated MDS was not completed or transmitted when the resident left the facility.
MDS assessments were inaccurately coded for three residents. One resident’s transmitted MDSs used a different first name than the resident’s legal name, another resident’s PASRR Level II showed serious mental illness but the MDS did not reflect it, and a third resident’s MDS incorrectly indicated anticoagulant use despite no current anticoagulant order or administration. The MDSC verified the coding errors in the assessments.
A resident with an intact BIMS score and a stage 2 pressure injury on the left buttock had physician orders for wound cleanser, Santyl ointment, and a Mepilex dressing, as well as a facility policy requiring no-touch technique and hand hygiene between glove changes. During an observed dressing change, an RN repeatedly failed to perform hand hygiene between glove changes, removed a soiled dressing and cleansed the wound without using clean or sterile gauze, and applied Santyl directly to the wound bed with a gloved finger instead of an applicator, before placing a new Mepilex dressing.
Two residents with orders for Enhanced Barrier Precautions (EBP) due to open wounds did not receive required PPE use during high-contact care and wound care. One resident with bilateral venous stasis ulcers and an EBP order was assisted by a CNA with toileting and transfer without any PPE, and the resident reported that staff used only gloves, not gowns or face protection, during wound care and personal hygiene. Another resident with a stage 2 buttock pressure ulcer and an EBP order received wound care from an RN who wore gloves but no gown or face shield/mask while removing a soiled dressing and cleansing the wound. The facility’s IP confirmed that gowns and gloves are required for all residents on EBP and that high-contact activities such as transfers, toileting assistance, and wound care require EBP.
A resident with severe cognitive impairment attempted to suffocate their roommate with a pillow, but the facility failed to notify the resident's physician of this significant behavioral change. The incident involved two residents with dementia and anxiety, and the oversight was acknowledged by the facility's administration.
A resident with Alzheimer's and severe cognitive impairment was involved in an altercation with a roommate, but the facility failed to update the care plan to address aggressive behavior and noise sensitivity. Despite staff moving the resident to a different room, the care plan lacked necessary interventions, as confirmed by the DON.
The facility breached confidentiality by including two residents' medical records in a former RN's personnel file, which was then shared with an outside agency. The records contained sensitive information such as diagnoses and treatment orders. The NHA was unsure of their responsibilities and did not seek permission from the residents or their representatives.
The facility failed to maintain sanitary food storage and preparation practices, affecting all residents. Staff did not document food cooling temperatures, leading to potential cross-contamination, especially concerning for a lactose-intolerant resident. Additionally, staff did not follow proper hand hygiene, using the same gloves for multiple tasks, contrary to facility policy.
A resident with a history of cerebrovascular disease, dementia, and epilepsy was not offered the PCV20 vaccine as per CDC guidelines and facility policy. The Infection Preventionist misunderstood the guidelines, believing the vaccine discussion was between the resident and their physician. The resident's Power of Attorney for Healthcare wanted the vaccine administered if the physician agreed.
A facility failed to protect residents from sexual abuse by not supervising a resident with a known history of inappropriate sexual behavior. This led to two residents being inappropriately touched by the resident. The facility did not review or act upon the resident's pre-admission documentation indicating a history of such behavior, and no monitoring interventions were in place. The incidents were not immediately reported to authorities, and staff failed to report inappropriate comments made by the resident.
The facility failed to report an allegation of sexual abuse in a timely manner to the State Agency and local law enforcement. A resident reported inappropriate touching by another resident, but the facility delayed reporting the incident, contrary to their policy requiring immediate notification. The Nursing Home Administrator did not initially report the allegation, as it was deemed unsubstantiated without completing all necessary interviews. The residents involved had moderate cognitive impairments.
A facility failed to thoroughly investigate a sexual abuse allegation between two residents, initially dismissing the claim based on limited video footage and the alleged perpetrator's denial. The investigation was only expanded after a staff member's observation led to further video review, confirming the incident. This delay resulted in a late report to the State Agency and postponed protective measures.
Unsafe Food Storage, Sanitizing Logs, and Date Marking Deficiencies
Penalty
Summary
Food was not stored and prepared in a safe and sanitary manner. During an initial kitchen tour with the Interim Dietary Manager, the surveyor reviewed the facility’s 3-compartment sink and sanitizing bucket log and found that the log contained staff initials but did not document the PPM or temperature of the sanitizing solution. The Interim Dietary Manager could not confirm whether staff tested the temperature of the sanitizing solution used in the sink and sanitizing buckets. The report also noted that the Wisconsin Food Code requires routine monitoring of sanitizing solution temperature and chemical concentration, and that the Hydrion QT-40 test strips used by the facility require the test solution to be between 65 and 75 degrees Fahrenheit. The surveyor also observed inconsistent dating and labeling of resident food in the main cooler. The cooler contained a container of sliced eggs dated 3/18, a container of ham salad dated 3/19, and an open-to-air half head of cabbage with no date. The Interim Dietary Manager later stated the facility’s previous practice was to discard all food after 3 days, but that it had recently been changed to 7 days, and acknowledged concerns with labeling and discarding food based on food safety guidelines.
Failure to Transmit Required Discharge MDS
Penalty
Summary
The facility did not ensure timely transmittal of a Resident Assessment Information/Minimum Data Set (RAI/MDS) assessment for 1 of 14 sampled residents, R23. R23 was admitted to the facility and was transferred to the hospital on 12/5/25, did not return to the facility, and a Discharge MDS assessment was not transmitted for the hospitalization. During record review of the facility’s MDS submissions, surveyors found no Discharge MDS assessment had been transmitted for R23. On 3/24/26 at 2:51 PM, the MDS Coordinator confirmed that a Discharge-Return Anticipated MDS assessment was not completed or transmitted when R23 was transferred to the hospital or when R23 did not return to the facility, and stated that it is the facility’s practice to transmit Discharge MDS assessments when residents are discharged from the facility.
MDS assessments were inaccurately coded for three residents
Penalty
Summary
The facility did not accurately code MDS 3.0 assessments for three residents. The facility’s MDS policy states residents are assessed using a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan, and federal regulations require an initially and periodically comprehensive, accurate, and standardized assessment using the RAI. Survey review found that one resident’s transmitted MDS assessments were not consistently reflected under the resident’s legal first name: the Entry Tracking MDS dated 12/13/24 and Comprehensive MDS dated 12/26/24 were transmitted with a different first name than later PPS Part A Discharge, Quarterly, and Death Tracking MDS assessments. The MDS coordinator stated she was not aware the first name had been changed in the MDS system and confirmed the resident’s legal name should be used. Survey review also found coding errors for two other residents. One resident’s PASRR Level II screen dated 1/8/25 indicated the resident met the federal definition of a serious mental illness, but the Significant Change MDS dated 3/28/25 did not indicate serious mental illness; the MDS coordinator verified the assessment was coded incorrectly at Section A1500.3. Another resident’s MDS dated 3/11/26 indicated receipt of anticoagulant medication, but the resident did not have an anticoagulant order and did not receive anticoagulant medication; the resident’s MAR showed the most recent anticoagulant, enoxaparin, had been ordered for DVT prevention from 9/3/25 through 9/22/25. The MDS coordinator reviewed the assessment and verified it was coded incorrectly at Section N.
Improper Hand Hygiene and Wound Care Technique During Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves failure to provide appropriate pressure ulcer care and to follow infection control practices during wound treatment for one resident. The resident had a documented stage 2 pressure injury on the left buttock, with medical orders to cleanse the wound with wound cleanser, apply a thin layer of Santyl ointment, and cover with a Mepilex padded dressing. The facility’s Clean Dressing Change policy required a no-touch technique for ointment application, use of applicators such as tongue blades, cleansing the wound as ordered, patting dry with gauze, and performing hand hygiene before donning clean gloves to apply topical treatments and dressings. During an observed wound care episode, the RN first donned gloves to wipe the resident after toileting and then removed the gloves, but did not perform hand hygiene before donning new gloves to remove the existing dressing, which contained yellow drainage. After removing those gloves, the RN again failed to cleanse hands before donning clean gloves to spray the wound with cleanser and wiped the wound with a washcloth instead of clean or sterile gauze. While wearing the same gloves, the RN used a gloved finger to remove Santyl from its container and apply it directly to the wound bed, contrary to the facility’s no-touch policy. The RN then removed the gloves, again without hand hygiene, donned new gloves, applied and dated a Mepilex dressing, and removed the gloves without cleansing hands between glove changes. The DON later confirmed that staff were expected to perform hand hygiene between glove changes and to use appropriate materials and applicators for cleansing and ointment application.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Enhanced Barrier Precautions (EBP) policy for residents with wounds requiring high-contact care. The facility’s policy, revised 7/17/25, requires an EBP order for residents with wounds, including venous stasis ulcers and pressure ulcers, and specifies that gowns and gloves must be used for high-contact resident care activities such as dressing, bathing, transferring, toileting assistance, and wound care. The policy also requires hand hygiene before and after applying or removing PPE and before and after handling clean or soiled dressings or linens. For one resident (R1), who had diagnoses including a right femur fracture with routine healing, osteoporosis with pathological fracture, and chronic venous insufficiency with bilateral lower extremity venous stasis ulcers requiring wound care, the medical record contained an order for EBP related to vascular ulcers to both lower extremities every shift. R1 also had an order for wound care to bilateral leg ulcers twice weekly. During observation, a CNA entered and exited R1’s room without donning any PPE while assisting with toileting and a transfer. The CNA stated PPE was not worn because they believed only wound care required EBP. R1 later reported having wounds with dressings on both legs, that staff performed wound care twice weekly wearing gloves but not gowns or face shields/masks, and that staff assisted with transfers and personal hygiene without wearing gowns. For another resident (R4), who had diagnoses including a stage 2 pressure ulcer of the buttock, opioid dependence, and a non-displaced sacral fracture, the medical record contained an order for EBP related to a pressure area on the left buttock. During observation of wound care, an RN wore gloves but did not don a gown or face shield/mask while removing a dressing with yellow drainage, cleansing the wound with wound cleanser, and completing wound care. The RN confirmed that the resident was on EBP and acknowledged a gown should have been worn during wound care. The Infection Preventionist confirmed that both residents had EBP orders and that a gown and gloves are required for all residents on EBP, with face protection required when there is risk of splash, and verified that high-contact cares include bed changes, transfers, walking, toileting assistance, shaving, bathing, and wound care.
Failure to Notify Physician of Resident's Aggressive Behavior
Penalty
Summary
The facility failed to notify a physician when a resident, identified as R2, exhibited physically aggressive behavior towards another resident, R1. R2, who had a history of making threats to suffocate R1 with a pillow, attempted to place a pillow over R1's face on February 20, 2025. Despite the severity of the incident, R2's physician was not informed of this significant change in behavior, which is a requirement under the facility's Clinical Change of Condition policy. This policy mandates that any change in a resident's status should prompt an assessment and notification of the physician. R2 was admitted to the facility with diagnoses including Alzheimer's disease, dementia, and anxiety, and had a severely impaired cognition as indicated by a BIMS score of 5 out of 15. R1, who was also severely cognitively impaired with a BIMS score of 3 out of 15, was the victim of the incident. The facility's focus was on R1 as the impacted resident, and they failed to consider the necessity of notifying R2's physician about the behavioral change. This oversight was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged that R2's physician should have been notified.
Failure to Update Care Plan for Resident's Aggressive Behavior
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised to address specific behavioral issues. The resident, who had diagnoses including Alzheimer's disease, dementia, psychotic disturbance, mood disturbance, and anxiety, was involved in an altercation with a roommate. The incident involved the resident placing a pillow over the roommate's head to silence them from yelling. Despite this incident, the resident's care plan was not updated to include interventions for aggressive behavior, resident-to-resident altercations, or the impact of loud noise, which was known to agitate the resident. Interviews with facility staff revealed that the resident was moved to a different room to promote safety, but there was no care plan or Kardex addressing the resident's aggressive behavior. The Director of Nursing confirmed that the care plan lacked interventions for noise reduction or providing a private room to mitigate the resident's aversion to loud noise. The failure to update the care plan was acknowledged by the facility's administration, indicating a lapse in adhering to their policy on revising care plans following changes in a resident's needs.
Confidentiality Breach of Residents' Medical Records
Penalty
Summary
The facility failed to ensure the confidentiality of medical records for two residents, R4 and R5, as part of a deficiency identified during a survey. Registered Nurse (RN)-D, after their last day of employment, requested a copy of their personnel file, which inadvertently included protected health information (PHI) from the medical records of R4 and R5. Specifically, R4's fall report and R5's Treatment Administration Record (TAR) were included in RN-D's personnel file. The fall report for R4 contained sensitive information such as age, room number, physician, diagnoses, and treatment orders, while R5's TAR included wound and behavior orders, diet orders, diagnoses, room number, physician, and date of birth. The Nursing Home Administrator (NHA)-A confirmed that RN-D's personnel file was provided to an outside government agency due to a workman's compensation claim, which included R4's fall report. However, NHA-A was uncertain about the inclusion of R5's TAR in the file. Furthermore, NHA-A admitted to not being sure of their responsibilities regarding the release of medical records and confirmed that neither R4 nor R5, nor their representatives, were informed or asked for permission to release their medical records to a former employee or an outside agency.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, which had the potential to affect all 45 residents. During a kitchen tour, it was observed that staff did not monitor or document food cooling temperatures as required by the 2022 Wisconsin Food Code. Several pre-cooked and cooled foods were found in the walk-in cooler and freezer without any documentation of the cooling process. The Dietary Manager confirmed that the facility did not have a process for documenting food cooling and lacked cooling logs for the stored foods. Cross-contamination was also observed during meal service. A cook used the same scoop for different food items without cleaning it between uses, which could lead to cross-contamination. This was particularly concerning for a resident with lactose intolerance, as the same scoop was used for both regular and fortified mashed potatoes, the latter containing milk. The Dietary Manager was unaware of this practice and confirmed the potential for cross-contamination. Additionally, staff did not follow appropriate hand hygiene and safe food handling practices. Observations showed that cooks used the same gloves to handle various items, including food scoops, meal tickets, and residents' plates, without changing gloves or performing hand hygiene. This practice was against the facility's policy, which required single-use gloves or tongs for handling food. The Dietary Manager confirmed that all cooks and dietary aides were trained on appropriate hand hygiene, yet the policy was not followed during lunch service.
Failure to Offer PCV20 Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the PCV20 vaccine as per CDC guidelines and the facility's own policy. The resident, who had a history of cerebrovascular disease, dementia, and epilepsy, was admitted to the facility and had previously received a PCV13 vaccine in 2016 and a PPSV23 vaccine in 2019. According to the CDC recommendations and the facility's policy, the resident was due to be offered the PCV20 vaccine on or after August 16, 2024. However, this was not done. The deficiency occurred because the Infection Preventionist (IP) did not offer the PCV20 vaccine to the resident, mistakenly interpreting the CDC recommendations and believing that the discussion about the vaccine should occur between the resident and their physician. The resident's Power of Attorney for Healthcare was contacted and expressed a desire for the resident to receive the PCV20 vaccine if the physician agreed. The Nursing Home Administrator expected staff to offer vaccines according to CDC recommendations and the facility's policy, but this expectation was not met in this instance.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically sexual abuse, by not adequately supervising a resident with a known history of inappropriate sexual behavior. This deficiency involved two residents, R2 and R4, who were subjected to inappropriate touching by R1. R1 had a documented history of sexually inappropriate behavior from a previous facility, which was not reviewed or acted upon by the staff at the time of R1's admission. As a result, R1 was placed in a unit with vulnerable residents without any monitoring interventions in place. On 6/6/24, R2 reported to an Activity Aide that R1 had touched R2's breast in the hallway. Initially, the Nursing Home Administrator and Director of Nursing reviewed camera footage and interviewed both residents, concluding that the allegation did not occur. However, further review of the footage revealed that R1 had indeed touched R2 inappropriately in the lounge. Additionally, another resident, R4, later reported that R1 had also touched R4's breast on a previous occasion. These incidents were not immediately reported to local law enforcement or the State Agency, and the facility did not implement monitoring interventions for R1 until after the incidents were confirmed. The facility's failure to read and act upon R1's pre-admission documentation, which indicated a history of inappropriate sexual behavior, contributed to the deficiency. Staff interviews conducted after the incidents revealed that R1 had made sexually inappropriate comments to staff members, which were not reported to administrative staff. The lack of supervision and failure to implement a care plan for R1's behavior led to a finding of immediate jeopardy, as the facility did not ensure a safe environment free from abuse for its residents.
Removal Plan
- Removed R1 from the secured dementia unit
- Initiated facility-wide education related to sexual behaviors/signs of predator
- Initiated facility-wide education related to new admissions with inappropriate behaviors
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse in a timely manner to the State Agency (SA) and local law enforcement, as required by their policy and federal regulations. On June 6, 2024, a resident (R2) reported to a staff member that another resident (R1) had touched them inappropriately without consent. Despite the facility's policy mandating immediate reporting of such allegations, the incident was not reported to local law enforcement until the following morning and to the SA later that afternoon. The facility's policy requires that allegations of abuse be reported no later than two hours after discovery or forming the suspicion. The Nursing Home Administrator (NHA) did not initially report the allegation because the facility did not substantiate it after reviewing camera footage and interviewing the involved residents. However, the NHA acknowledged that other resident and staff interviews were not completed before determining the allegation was unsubstantiated. The incident was later discovered on camera footage, prompting the facility to report the allegation to the appropriate authorities. The residents involved had moderate cognitive impairments, with R1 having a history of stroke and other medical conditions, and R2 having dementia and other diagnoses.
Inadequate Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough investigation of an allegation of sexual abuse involving two residents. On June 6, 2024, a resident reported being inappropriately touched by another resident without consent. The facility's initial investigation was inadequate as it relied solely on video footage review and the denial of the alleged perpetrator, without conducting interviews with other potential witnesses or involved parties. This led to the premature dismissal of the allegation. The facility's investigation was only expanded after a staff member reported seeing the two residents together in a common area, prompting a review of additional video footage that confirmed the incident. This delay resulted in a late report to the State Agency and postponed the initiation of further investigation and protective measures. Additionally, during the subsequent investigation, another resident reported a similar incident involving the same alleged perpetrator, which had not been previously reported to staff.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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